Neuro Lip/Saunders L2

when the nurse is assessing the client with a cord transection above t5 for possible complications, which complication is least likely to occur? 1. diarrhea 2. paralytic ileus 3. stress ulcers 4. intra abdominal bleeding

1. diarrhea

The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg appears fractured. Which intervention should the nurse take? 1. Try to reduce the fracture manually. 2. Assist the victim to get up and walk to the sidewalk. 3. Leave the victim for a few moments to call an ambulance. 4. Stay with the victim and encourage him or her to remain still.

4. Stay with the victim and encourage him or her to remain still.

the nurse is caring for a client who begins to experience seizure activity while in bed. which actions should the nurse take? select all that apply 1. loosening restrictive clothing 2. restraining the clients limbs 3. removing the pillow and raising padded side rails 4. positioning the client to the side, if possible, with the head forward 5. keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist

1. loosening restrictive clothing 3. removing the pillow and raising padded side rails 4. positioning the client to the side, if possible, with the head forward

the client arrives at the ED complaining of back spasms. the client states "I have been taking 2 to 3 aspirin every 4 hours for the last week and its hasn't helped my back." since acetylsalicylic acid intoxication is suspected, the nurse should assess the client for which manifestation? 1. tinnitus 2. diarrhea 3. constipation 4. photosensitivity

1. tinnitus

a history of which factors will complicate the recovery from a concussion? select all that apply 1. asthma 2. ADHD 3. depression 4. migraines 5. obesity 6. previous concussion

2. ADHD 3. depression 4. migraines 6. previous concussion

which finding in an infant with myelo. should be reported to the HCP as a sign of intracranial pressure? 1. minimal lower extremity movement 2. a high pitched cry 3. overflow voiding only 4. a fontanelle that bulges with crying

2. a high pitched cry

the nurse should perform ROM exercises on which clients? select all that apply a client who: 1. has septic joints 2. has temporary loss of sensation 3. is unconscious 4. has plantar flexion of the foot 5. has supination of the hand

2. has temporary loss of sensation 3. is unconscious

when developing the plan of care for a child who unconscious after a serious head injury, the nurse would expect to place the child in which position? 1. prone with hips and knees slightly elevated 2. lying on the side with the head of the bed elevated 3. lying on the back in the trendelenburg position 4. in the semi fowlers position with the arms at the side

2. lying on the side with the head of the bed elevated

after placing an infant with myelo. in an Isolette shortly after birth, the nurse should use which indicator as the best way to determine the effectiveness of this intervention? 1. the partial pressure of arterial oxygen remains between 94 and 100 mm Hg 2. the axillary temp remain between 97 and 98 F 3. the bilirubin level remains stable 4. weight increases by about 1 oz per day

2. the axillary temp remain between 97 and 98 F

a client is a moderate risk for falling using a fall risk assessment scale. what should the nurse instruct the UAP to do? 1. remain with the client during toileting 2. reorient the client to time and place every hour 3. activate the bed and chair alarms 4. apply a protective chest restraint

3. activate the bed and chair alarms

the nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. which observation indicates that spinal shock persists? 1. hyperreflexia 2. positive reflexes 3. flaccid paralysis 4. reflex emptying of the bladder

3. flaccid paralysis

a preschooler with a history of repaired myelo. is in the ED with wheezing and skin rash. which questions should the nurse ask the parent first? 1. is your child taking any medications? 2. who brought your child to the emergency department? 3. is your child allergic to bananas or any other food? 4. what are you doing to treat your child's skin rash?

3. is your child allergic to bananas or any other food?

a client with GB syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. which strategy should the nurse incorporate in the plan of care to help the client cope with this illness? 1. giving client full control over care decisions and restricting visitors 2. providing positive feedback and encouraging active range of motion 3. providing information, giving positive feedback and encouraging relaxation 4. providing IV administered sedatives, reducing distractions and limiting visitors

3. providing information, giving positive feedback and encouraging relaxation

the nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. in determining the client's risk factors, the nurse should question the client about an allergy to which food item? 1. eggs 2. milk 3. yogurt 4. bananas

4. bananas

a client recovering from a head injury is participating in care. the nurse determines that the client understands measures to prevent elevations in ICP if the nurse observes the client doing which activity? 1. blowing the nose 2. isometric exercises 3. coughing vigorously 4. exhaling during repositioning

4. exhaling during repositioning

a client with MS is experiencing bowel incontinence and is starting a bowel retraining program. which strategy is not appropriate? 1. eating a diet high in fiber 2. setting a regular time for elimination 3. using an elevated toilet seat 4. limiting fluid intake to 1,000 mL/day

4. limiting fluid intake to 1,000 mL/day

the nurse creates a plan of care for a child at risk for tonic-clonic seizures. in the plan of care the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside? 1. emergency cart 2. tracheotomy set 3. padded tongue blade 4. suctioning equipment and oxygen

4. suctioning equipment and oxygen

the nurse should assess which clients are at risk for falling? select all that apply client who is: 1. 45 years of age, in hospice with terminal cancer, and receiving morphine every 2 hours 2. 70 years, hospitalized for lung biopsy, and receiving no medications 3. 62 years, recovering from breast biopsy in outpatient surgery and has a fear of falling 4. 80 years, in a locked facility for clients with cognitive impairment 5. 75 years, and recovering at home from hip replacement surgery on the left hip

1. 45 years of age, in hospice with terminal cancer, and receiving morphine every 2 hours 3. 62 years, recovering from breast biopsy in outpatient surgery and has a fear of falling 4. 80 years, in a locked facility for clients with cognitive impairment 5. 75 years, and recovering at home from hip replacement surgery on the left hip

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. 1. Padding the side rails of the bed 2. Placing an airway at the bedside 3. Placing the bed in the high position 4. Putting a padded tongue blade at the head of the bed 5. Placing oxygen and suction equipment at the bedside 6. Flushing the intravenous catheter to ensure that the site is patent

1. Padding the side rails of the bed 2. Placing an airway at the bedside 5. Placing oxygen and suction equipment at the bedside 6. Flushing the intravenous catheter to ensure that the site is patent

which client has the greatest risk for latex allergies? 1. a woman who is admitted for her 7th surgery 2. a man who works as a sales clerk 3. a man with well controlled type 2 diabetes 4. a woman who is having laser surgery

1. a woman who is admitted for her 7th surgery

which statement made by the parent of a school age child who has had a craniotomy for a brain tumor would warrant further explanation by the nurse? 1. after this I will never let her out of my sight again 2. I hope that she will be able to go back to school soon 3. I wonder how long it will be before she can ride her bike 4. her best friend is eager to see her; I hope she won't be upset

1. after this I will never let her out of my sight again

the nurse is caring for a client being treated for fat embolus after multiple fractures. which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? 1. clear mentation 2. minimal dyspnea 3. oxygen saturation of 85% 4. arterial oxygen level of 78 mm Hg

1. clear mentation

The client has a latex allergy. What should the nurse teach the client to do before having surgery? Select all that apply. 1. determine that there will be a latex safe environment for surgery 2. report symptoms experienced with the latex allergy (e.g. rhinitis, conjunctivitis, flushing) 3. notify HCPs at the surgery center 4. wear a stainless steel medical alert bracelet into the surgical site 5. ask to have the surgery at a hospital

1. determine that there will be a latex safe environment for surgery 2. report symptoms experienced with the latex allergy (e.g. rhinitis, conjunctivitis, flushing) 3. notify HCPs at the surgery center

an unconscious client with multiple injuries to the head and neck arrives in the ED. what should the nurse do first? 1. establish an airway 2. determine the identity of the client 3. stop bleeding from open wounds 4. check for a neck fracture

1. establish an airway

cyclobenzaprine is prescribed for a client for muscle spasms and the nurse is reviewing the client's record. which disorder, if noted in the record, would indicate a need to contact the PCP about the administration of this medication? 1. glaucoma 2. emphysema 3. hypothroidism 4. diabetes mellitus

1. glaucoma

to prevent pulmonary emboli in a client who has had abdominal surgery, what should the nurse do? 1. have the client perform leg exercises every hour while awake 2. encourage the client to cough and deep breathe 3. massage the client's calves 4. have the client wear antiembolism stockings when out of bed

1. have the client perform leg exercises every hour while awake

a client has a Jackon-Pratt drainage tube in place the first day after surgical repair of a ruptured diverticulum. the client asks the nurse the purpose of the drain. what should the nurse tell the client? the drainage tube is used to prevent: 1. infection in the peritoneal cavity 2. bleeding into the peritoneal cavity 3. pressure on the bladder 4. pressure on the gallbladder

1. infection in the peritoneal cavity

a client with a spinal cord injury is prone to experiencing autonomic dysreflexia. the nurse should include which measures of in the plan of care to minimize the risk of occurence? select all that apply 1. keeping the linens wrinkle free under the client 2. preventing unnecessary pressure on the lower limbs 3. limiting bladder catheterization to once every 12 hours 4. turning and repositioning the client at least every 2 hours 5. ensuring the client has a bowel movement at least once a week

1. keeping the linens wrinkle free under the client 2. preventing unnecessary pressure on the lower limbs 4. turning and repositioning the client at least every 2 hours

the nurse is documenting care of a client who is restrained in bed with bilateral wrist restraints. following assessment of the restraints, what should the nurse's documentation include? select all that apply 1. nutrition and hydration needs 2. capillary refill 3. continued need for restraints 4. need for medication 5. skin integrity

1. nutrition and hydration needs 2. capillary refill 3. continued need for restraints 5. skin integrity

the HCP has prescribed 5 mg warfarin orally for a hospitalized client. in planning care for this client, the nurse should verify that which services have been contacted? check all that apply 1. pharmacy 2. dietary 3. laboratory 4. discharge planning 5. risk management

1. pharmacy 2. dietary 3. laboratory

the nurse is instituting a falls prevention program. which personnel should be involved in the program? select all that apply 1. registered nurses 2. insurance providers 3. unlicensed assistive personnel 4. housekeeping services 5. family members 6. client

1. registered nurses 3. unlicensed assistive personnel 4. housekeeping services 5. family members 6. client

the client has been diagnosed with septic arthritis in a hip joint. which outcomes are desired from a client focused teaching plan? select all that apply 1. report pain that is severe enough to limit activities 2. discuss how to take prescribed medications 3. describe how the application of a heating pad set on high readily resolves edema 4. describe the septic arthritis physiologic process 5. explain the importance of supporting the affected joint 6. describe how to use ambulatory aids and assistive devices

1. report pain that is severe enough to limit activities 2. discuss how to take prescribed medications 4. describe the septic arthritis physiologic process 5. explain the importance of supporting the affected joint 6. describe how to use ambulatory aids and assistive devices

the nurse is developing a plan to teach a client deep breathing exercises to expand collapsed alveoli and prevent postoperative atelectasis and pneumonia. what information should be included in the plan? select all that apply 1. splint or support the incision to promote maximal comfort 2. inhale slowly through the nostrils; exhale through pursed lips 3. hold the breath for about 5 seconds to expand the alveoli 4. repeat this breathing method 5 to 10 times hourly 5. close one nostril while inhaling

1. splint or support the incision to promote maximal comfort 2. inhale slowly through the nostrils; exhale through pursed lips 3. hold the breath for about 5 seconds to expand the alveoli 4. repeat this breathing method 5 to 10 times hourly

the nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. which client activity suggests that teaching most effective? 1. taking medications as scheduled 2. eating large balanced meals 3. doing muscle strengthening exercises 4. doing all chores early in the day while less fatigued

1. taking medications as scheduled

the nurse is caring for a client who has had spinal fusion, with insertion of hardware. the nurse would be most concerned with which assessment finding? 1. temp 101.6 F 2. complaints of discomfort during repositioning 3. old bloody drainage outlined on the surgical dressing 4. discomfort during coughing and deep breathing exercises

1. temp 101.6 F

the nurse is assigned to care for a client with complete right sided hemiparesis from a stroke. which characteristics are associated with this condition? select all that apply 1. the client is aphasic 2. the client has weakness on the right side of the body 3. the client has complete bilateral paralysis of the arms and legs 4. the client has weakness on the right side of the face and tongue 5. the client has lost the ability to move the right arm but is able to walk independently 6. the client has lost the ability to ambulate independently but is able to feed and bathe without assistance

1. the client is aphasic 2. the client has weakness on the right side of the body 4. the client has weakness on the right side of the face and tongue

upon waking up in the postanesthesia care unit and seeing a drain with bright red fluid in it exiting from his total hip incision, I client asks the nurse "is this the way it's supposed to be?" what should the nurse tell the client? 1. the drainage is blood and fluid that must be drained out for healing 2. dont worry about it. I'll expain it when you are more awake. 3. this blood is being kept sterile and will be given back to you 4. I'll give you something to make you sleep so you wont worry

1. the drainage is blood and fluid that must be drained out for healing

the nurse is creating a plan of care for a child who is at risk for seizures. which interventions app;y if the child has a seizure? select all that apply 1. time the seizure 2. restrain the child 3. stay with the child 4. place the child is a prone position 5. move furniture away from the child 6. insert a padded tongue blade in the child's mouth

1. time the seizure 3. stay with the child 5. move furniture away from the child

which interventions apply in the care of a client at a high risk for an allergenic response to a latex allergy? select all that apply 1. use nonlatex gloves 2. use medications from glass ampules 3. place the client in a private room only 4. keep a latex safe supply cart available in the client's area 5. avoid the use of medication vials that have rubber stoppers 6. use a blood pressure cuff from an electronic device only to measure the blood pressure

1. use nonlatex gloves 2. use medications from glass ampules 4. keep a latex safe supply cart available in the client's area 5. avoid the use of medication vials that have rubber stoppers

the nurse is caring for the client with increased ICP as a result of a head injury. the nurse would note which trend in vital signs if the ICP is rising? 1. +temp, +pulse, +respirations, -BP 2. +temp, -pulse, -respirations, +BP 3. -temp, -pulse, +respirations, -BP 4. -temp, +pulse, -respirations, +BP

2. +temp, -pulse, -respirations, +BP

as a first step in teaching a woman with a spinal cord injury and quadriplegia about her sexual health, the nurse assesses her understanding of her current sexual functioning. which statement by the client indicates she understands her current ability? 1. I wont be able to have sexual intercourse until the urinary catheter is removed. 2. I can participate in sexual activity but might not experience orgasm 3. I cant have sexual intercourse because it causes hypertension, but other sexual activity is ok 4. I should be able to participate in sexual activity but I'll be infertile

2. I can participate in sexual activity but might not experience orgasm

the nurse has completed discharge instructions for a client with application of a halo device who sustained a cervical spinal cord injury. which statement indicates that the client needs further clarification of the instructions? 1. I will use a straw for drinking 2. I will drive only during the daytime 3. I will be careful because the device alters balance 4. I will wash the skin daily under the lamb's wool liner of the vest

2. I will drive only during the daytime

the nurse assesses a client who has just received morphine sulfate. the client's blood pressure is 90/50, pulse 58, 4 breaths/min. what should the nurse do first? 1. call the rapid response team 2. administer naloxone hydrochloride 3. start oxygen at 2 liters/min 4. obtain a stat ECG

2. administer naloxone hydrochloride (stat, hehehe)

a client has a neurological deficit involving the limbic system. on assessment, which finding is specific to this type of deficit? 1. is disoriented to person, place, and time 2. affect is flat, with periods of emotional lability 3. cannot recall what was eaten for breakfast today 4. demonstrates inability to add and subtract; does not know who the president of the U.S. is

2. affect is flat, with periods of emotional lability

the nurse is preparing discharge instructions for a client who sustained a skeletal muscle injury and is receiving baclofen. which instruction should be included in the teaching plan? 1. restrict fluid intake 2. avoid the use of alchol 3. stop the medication if diarrhea occurs 4. notify the PCP if fatigue occurs

2. avoid the use of alchol

four days after surgery for internal fixation of a C3-C4 fracture, a nurse is moving a client from the bed to the wheelchair. the nurse is checking the wheelchair for correct features for this client. which features of the wheelchair are appropriate for the needs of this client? select all that apply 1. back at the level of the client's scapula 2. back and head that are high 3. seat that is lower than normal 4. seat with firm cushions 5. chair controlled by client's breath

2. back and head that are high 3. seat that is lower than normal 5. chair controlled by client's breath

after surgery a client was treated for postoperative nausea and vomiting and now is experiencing hypotension and tachycardia. the nurse should review the medication record to determine if the client has received which medication? 1. ondansetron hydrochloride 2. droperidol 3. prochlorperazine 4. promethazine

2. droperidol

atropine sulfate is contraindicated as a preoperative medication for which client? a client with: 1. diabetes 2. glaucoma 3. pyelonephritis 4. COPD

2. glaucoma

the nurse has given medication instructions to a client receiving phenytoin. which statement indicates that the client has an adequate understanding of the instructions? 1. alcohol is not contraindicated while taking this medication 2. good oral hygiene is needed, including brushing and flossing 3. the medication dose may be self adjusted depending on side effects 4. the morning dose of the medication should be taken before a serum medication level is drawn

2. good oral hygiene is needed, including brushing and flossing

the nurse is evaluating a client who is using a flow incentive spirometer following abdominal surgery 1 day ago. the client is performing the procedure correctly when the client does what? select all that apply 1. inhales before using the spirometer 2. inhales for 3 seconds following fully expanding the lungs 3. coughs after using the spirometer 4. uses the spirometer once every 8 hours 5. exhales passively before using the spirometer 6. sits upright

2. inhales for 3 seconds following fully expanding the lungs 3. coughs after using the spirometer 5. exhales passively before using the spirometer 6. sits upright

the nurse is caring for a client with chronic back pain. codeine has been prescribed for the client. specific to the medication, which intervention should the nurse include in the plan of care while the client is taking this medication? 1. monitor radial pulse 2. monitor bowel activity 3. monitor apical heart rate 4. monitor peripheral pulses

2. monitor bowel activity

a client has had a nasogastric tube connected to low intermittent suction. what is the client at risk for? 1. confusion 2. muscle cramping 3. edema 4. tremors

2. muscle cramping

the nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. the nurse should use which technique to test the client's peripheral response to pain? 1. sternal rub 2. nailbed pressure 3. pressure on the orbital rim 4. squeezing of the sternocleidomastoid muscle

2. nailbed pressure

which nursing action does not aid in meeting the goal of clear breath sounds? 1. offering pain relief before having the client cough 2. providing a minimum of 1000 ml of fluid per day 3. using an incentive spirometer 4. assisting with early ambulation

2. providing a minimum of 1000 ml of fluid per day

an infant with a diagnosis of hydrocephalus is scheduled for surgery. which is the priority nursing intervention in the preoperative period? 1. test the urine for protein? 2. reposition the infant frequently 3. provide a stimulating environment 4. assess blood pressure every 15 minutes

2. reposition the infant frequently

the surgeon prescribes cefazolin 1 g to be given IV at 0730 when the client's surgery is scheduled at 0800. what is the primary reason to start the antibiotic exactly at 0730? 1. legally the medication has to be given at the prescribed time 2. the antibiotic is most effective in preventing infection if it is given 30 to 60 minutes before the operative incision is made. 3. the postoperative dose of cefazolin needs to be started exactly 8 hours after the preoperative dose of cefazolin 4. the peak and titer levels are needed for antibiotic therapy

2. the antibiotic is most effective in preventing infection if it is given 30 to 60 minutes before the operative incision is made.

merperidine had been prescribed for a client to treat pain. which side and adverse effect should the nurse monitor for? select all that apply 1. diarrhea 2. tremors 3. drowsiness 4. hypotension 5. urinary frequency 6. increased respiratory rate

2. tremors 3. drowsiness 4. hypotension

the nurse unit manager is making rounds on a team of clients and notices a client with a color coded armband that indicates the client is at risk for falling walking down the hall unassisted. the client is at the end of the hallway farthest from the client's room but is not tired. what should the nurse do first? 1. obtain a wheel chair and take the client back to the room 2. walk with the client back to the room and assist the client to get in a bed or a chair 3. locate an UAP to walk with the client back to the room 4. instruct the client to walk only in the room at this time

2. walk with the client back to the room and assist the client to get in a bed or a chair

the nurse is planning care for a group of clients who have had total hip replacement. of the clients listed below who is at highest risk for infection and should be assessed first? 1. 55 year old, 6 feet tall and weighs 180 lbs 2. 90 year old who lives alone 3. 74 year old who has periodontal disease with periodonitis 4. 75 year old who has asthma and uses an inhaler

3. 74 year old who has periodontal disease with periodonitis

the nurse is teaching the client about deep breathing techniques. which statement from the client indicates the need for additional education? 1. I will use my incentive spirometer every hour while I'm awake 2. I should place my hands lightly over my lower ribs and upper abdomen 3. I should get into a comfortable position before doing my breathing exercises 4. I should take four deep breaths and then cough deeply from the lungs

3. I should get into a comfortable position before doing my breathing exercises

which statement by the parent of an infant with a repaired upper lumbar myelo. indicates that the parent understands the nurse's teaching at the time of discharge? 1. I can apply a heating pad to his lower back 2. I will be sure to keep him away from other children 3. I will call the HCP if his urine has a funny smell 4. I will prop him on his pillows to keep him from rolling over

3. I will call the HCP if his urine has a funny smell

the parent brings the child to the clinic after discharge from the hospital for GB syndrome. which statement by the parent indicates that the discharge plan is being followed? 1. she and her sister argue all day 2. I have to bribe her to get her to do her exercises 3. I will take her to the pool where she can exercise with the other children 4. she has missed a few of her therapy sessions because she often sleeps

3. I will take her to the pool where she can exercise with the other children

the parents of a child recently diagnosed with cerebral palsy ask the nurse about the limitations of the disorder. the nurse responds by explaining that the limitations occur as a result of which pathophysiological process? 1. an infectious disease of the central nervous system 2. an inflammation of the brain as a result of a viral illness 3. a chronic disability characterized by impaired muscle movement and posture 4. a congenital condition that results in moderate to severe intellectual disabilites

3. a chronic disability characterized by impaired muscle movement and posture

the nurse is evaluating the status of a client who had a craniotomy 3 days ago. which assessment finding would indicate that the client is developing meningitis as a complication of surgery? 1. a negative kernig's sign 2. absence of nuchal rigidity 3. a positive brudzinki's sign 4. a glasgow coma scale score of 15

3. a positive brudzinki's sign

the postoperative nursing assessment of a clients ability to swallow fluids before providing oral fluids is based on the type of anesthesia given. which client would not have delayed fluid restrictions? the client who had: 1. a bronchoscopy under local anesthesia 2. a transurethal restriction of a bladder tumor under general anesthesia 3. a repair of carpal tunnel syndrome under local anesthesia 4. an inguinal herniorrhaphy with spinal and IV conscious sedation

3. a repair of carpal tunnel syndrome under local anesthesia

the nurse asssesses that the client is restless and becoming agitated in the immediate postoperative period. the client's oxygen saturation is 91%. what should the nurse do next? 1. administer a sedative 2. offer ice chips 3. adminster oxygen 4. apply wrist restraints

3. adminster oxygen

on the day of the surgery, a client has been breathing room air. the vital signs are normal and the O2 saturation is 89%. what should the nurse do first? 1. lower the head of the bed 2. notify the HCP 3. assist the client to take several deep breaths and cough 4. administer oxygen by nasal cannula as prescribed at 2 L/min

3. assist the client to take several deep breaths and cough

a client with a spinal cord injury has spinal shock. what should the nurse expect the client's bladder function to be at this time? 1. spastic 2. normal 3. atonic 4. uncontrolled

3. atonic

a client is complaining of low back pain that radiates down the left posterior thigh. the nurse should ask the client if the pain is worsened or aggravated by which factor? 1. bed rest 2. ibuprofen 3. bending or lifting 4. application of heat

3. bending or lifting

the nurse is administering an IV dose of methocarbamol to a client with a muscle skeletal injury. for which adverse effect should the nurse monitor? 1. tachycardia 2. rapid pulse 3. bradycardia 4. hypertension

3. bradycardia

on the day of the surgery, a client with diabetes who takes insulin on a sliding scale is to have nothing by mouth and all medications withheld. the client's 0600 glucose level is 300 mg/dL. what should the nurse do? 1. withhold all medications 2. administer the insulin dose dictated by the sliding scale 3. call the HCP for specific prescriptions based on the glucose level 4. notify the surgery department

3. call the HCP for specific prescriptions based on the glucose level

the nurse is caring for a client with a spinal cord injury. the client is experiencing blurred vision and has a blood pressure of 204/102. what should the nurse do first? 1. position the client on the left side 2. control the environment by turning the lights off and decreasing stimulation for the client 3. check the clients bladder for distension 4. administer pain medication

3. check the clients bladder for distension

a lumbar puncture is performed on a child suspected to have bacterial meningitis and cerebrospinal fluid is obtained for analysis. the nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis? 1. clear CSF, decreased pressure, and elevated protein level 2. clear CSF, elevated protein, and decreased glucose levels 3. cloudy CSF, elevated protein, and decreased glucose levels 4. cloudly CSF, decreased protein, and decreased glucose levels

3. cloudy CSF, elevated protein, and decreased glucose levels

the nurse empties a Jackson-Pratt drainage bulb. which nursing action ensures correct functioning of the drain? 1. irrigating it with normal saline 2. connecting it to low intermittent suction 3. compressing it and then plugging to establish suction 4. connecting it to a drainage bag and clamping it off

3. compressing it and then plugging to establish suction

the nurse is making rounds and observes the client receiving oxygen. what should the nurse do next? 1. position the mask lower on the client's nose 2. verify that the reservoir bag remains deflated 3. confirm that the flow rate is set to deliver oxygen at 6 to 10 L/min 4. loosen the elastic band on the client's face

3. confirm that the flow rate is set to deliver oxygen at 6 to 10 L/min

the nurse is going to lunch and is conducting a hand off care to the charge nurse. which information should the nurse communicate to the charge nurse during the hand off care communication? 1. tell the charge nurse that the nurse is going to lunch 2. verify that the charge nurse has assigned someone to take care of the client 3. give the charge nurse information about what care should be given while the nurse is at lunch 4. remind the charge nurse about the clients history and current medications

3. give the charge nurse information about what care should be given while the nurse is at lunch

Which finding should lead the nurse to decide that spinal shock was resolving in the adolescent with a spinal cord injury? 1. atonic urinary bladder 2. flaccid paralysis 3. hyperactive reflexes 4. widened pulse pressure

3. hyperactive reflexes

when planning to move a person with a possible spinal cord injury, the nurse should direct the team to move the client using which procedure? 1. limit movement of the arms by wrapping them next to the body 2. move the person gently to help reduce pain 3. immobilize the head and neck to prevent further injury 4. cushion the back with pillows to ensure comfort

3. immobilize the head and neck to prevent further injury

a client has sustained a closed fracture and has just had a cast applied to the affected arm. the client is complaining of intense pain. the nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. which problem may be causing this pain? 1. infection under the cast 2. the anxiety of the client 3. impaired tissue perfusion 4. the recent occurrence of the fracture

3. impaired tissue perfusion

the client with a spinal cord injury asks the nurse why the dietitian has recommended to decrease the total daily intake of calcium. which response by the nurse would provide the most accurate information? 1. excessive intake of dairy products makes constipation more common 2. immobility increases calcium absorption from the intestine 3. lack of weight bearing causes demineralization of the long bones 4. dairy products likely will contribute to weight gain

3. lack of weight bearing causes demineralization of the long bones

the nurse is analyzing the laboratory studies on a client receiving dantrolene to treat muscle spasms from an injury. which laboratory test would identify an adverse effect associated with the administration of this medication? 1. platelet count 2. creatinine level 3. liver function tests 4. blood urea nitrogen level

3. liver function tests

the nurse is preparing to start an IV infusion and has raised the head of the client's bed. after the nurse applies gloves to insert an IV catheter, the client begins to rub the eyes and wipe away nasal drainage. what should the nurse do first? 1. distract the clients attention 2. assess the client for pain 3. remove the gloves and assess the client's vital signs 4. lower the head of the client's bed

3. remove the gloves and assess the client's vital signs

a client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. in tears, one day he asks the nurse, "why can't I stop talking about these things? I know those days are gone forever." which response by the nurse conveys the best understanding of the client's behavior? 1. be patient. it takes time to adjust to such a massive loss 2. talking about the past is a form of denial. we have to help you focus on today 3. reviewing your losses is a way to help you work through your grief and loss 4. its a simple escape mechanism to go back and live again in happier times

3. reviewing your losses is a way to help you work through your grief and loss

a client is taking the prescribed dose of phenytoin to control seizures. results of a phenytoin blood level study reveal a level of 35 mcg/mL. which finding would be expected as a result of this laboratory result? 1. hypotension 2. tachycardia 3. slurred speech 4. no abnormal finding

3. slurred speech

a client who has type 1 diabetes is being prepared to have a craniotomy. the nurse is evaluating the client's understanding of the informed consent before witnessing the client's signature on the operative consent form. which statement from the client indicates that the nurse needs to contact the surgeon for further communication with the client? 1. we talked about the effect of my diabetes on healing 2. the surgeon explained how the craniotomy was done 3. there are no major risks from this surgery 4. I will die if the tumor is not removed from my brain

3. there are no major risks from this surgery

the home health care nurse visits a client who is taking phenytoin for control of seizures. during the assessment, the nurse notes that the client is taking birth control pills. which information should the nurse include in the teaching plan? 1. pregnancy must be avoided while taking phenytoin 2. the client may stop the medication if it is causing severe gastrointestinal effects 3. there is the potential of decreased effectiveness of birth control pills while taking phenytoin 4. there is the increased risk of thrombophlebitis while taking phenytoin and birth control pills together

3. there is the potential of decreased effectiveness of birth control pills while taking phenytoin

the nurse is evaluating a client in skeletal traction. when evaluating the pin sites, the nurse would be most concerned with which finding? 1. redness around the pin sites 2. pain on palpation at the pin sites 3. thick, yellow drainage from the pin sites 4. clear, watery drainage from the pin sites

3. thick, yellow drainage from the pin sites

a client with trigeminal neuralgia is being treated with carbamazepine 400 mg orally daily. which value indicates that the client is experiencing an adverse effect to the medication? 1. sodium level 140 mEq/L 2. uric acid level 4.0 mg/dL 3. white blood cell count 3000 mm 4. blood urea nitrogen level 10 mg/dL

3. white blood cell count 3000 mm

The right hand of the client with MS trembles severely whenever she attempts a voluntary action. she spills her coffee twice at lunch and cannot get her dress fastened securely. which is the best legal documentation in nurses' notes of the chart for this client assessment? 1. "has an intention tremor of the right hand" 2. "right-hand tremor worsens with purposeful acts 3. "needs assistance with dressing and eating due to severe trembling and clumsiness" 4. "slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup"

4. "slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup"

the nurse is instructing the client with parkinsons disease about preventing falls. which client statement reflects a need for further teaching? 1. I can sit down to put my pants and shoes on 2. I try to exercise every day and rest when I am tired 3. my son removed all loose rugs from my bedroom 4. I dont need to use my walker to get to the bathroom

4. I dont need to use my walker to get to the bathroom

the nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. the nurse determines that the client needs further teaching if the client makes which statement? 1. I will wash my face with cotton pads 2. I'll have to start chewing with on my unaffected side 3. I should rinse my mouth if tooth brushing is painful 4. I'll try to eat my food either very warm or very cold

4. I'll try to eat my food either very warm or very cold

a client with myasthenia gravis has become increasingly weaker. the PCP prepares to identify whether the client is reacting to an overdose of the medication or an increasing severity of the disease. an injection of the edophonium is administered. which finding would indicate that the client is in cholinergic crisis? 1. no change in the condition 2. complaints of muscle spasms 3. an improvement of the weakness 4. a temporary worsening of the condition

4. a temporary worsening of the condition

the nurse is caring for a client in the ED who has been diagnosed with bell's palsy. the client has been taking acetaminophen, and acetaminophen overdose is suspected. which antidote should the nurse prepare for administration if prescribed? 1. pentostatin 2. auranofin 3. fludarabine 4. acetylcyseine

4. acetylcyseine

prior to going to surgery, the client tells the nurse that it is not possible to hear without a hearing aid and asks to wear it to surgery and recovery. what is the nurse's best response? 1. explain to the client that it is policy not to take personal items to surgery because they may be lost or broken 2. tell the client that a nurse will bring the hearing aid as soon as the client wakes up 3. explain to the client that the premedication will cause sleepiness and it will not be necessary to hear anything 4. call the surgery unit to expain the client's concern and ask if the client can wear the hearing aid to surgery

4. call the surgery unit to expain the client's concern and ask if the client can wear the hearing aid to surgery

the nurse is assessing the adaptation of a client to changes in functional status after a stroke. which observation indicates to the nurse that the client is adapting most successfully? 1. gets angry with his family if they interrupt a task? 2. experiences bouts of depression and irritability 3. has difficulty with using modified feeding utensils 4. consistently uses adaptive equipment in dressing self

4. consistently uses adaptive equipment in dressing self

when developing the discharge plan for the parents of an infant who has undergone a myelo. repair, what information is most important for the nurse to include? 1. a list of available hospital services 2. schedule for daily home visits 3. chaplain referral for psychological support 4. daily care required by the infant

4. daily care required by the infant

the nurse is assessing a client with increased ICP. the nurse should notify the HCP about which early change in the client's condition? 1. widening pulse pressure 2. decrease in the pulse rate 3. dilated, fixed pupils 4. decrease in LOC

4. decrease in LOC

a client with trigeminal neuralgia tells the nurse that acetaminophen is taken daily for the relief of generalized discomfort. which lab value would indicate toxicity associated with the medication? 1. sodium level of 140 mEq/L 2. platelet count of 400,000 mm 3. prothrombin time of 12 seconds 4. direct bilirubin level of 2 mg/dL

4. direct bilirubin level of 2 mg/dL

the nurse is admitting a client with GB syndrome to the nursing unit. the client has complaints of inability to move both legs and reports a tingling sensation above the waistline. knowing the complications of the disorder, the nurse should bring which most essential items to the client's room? 1. nebulizer and pulse oximeter 2. BP cuff and flashlight 3. nasal cannula and incentive spirometer 4. electrocardiographic monitoring electrodes and intubation tray

4. electrocardiographic monitoring electrodes and intubation tray

a nurse is caring for a postsurgical client with two types of drains. which activities can the nurse delegate to the UAP? select all that apply 1. assess the drainage of an open drainage system such as a penrose drain 2. document drain site and surrounding tissue status 3. stabilize an open drainage system, such as a penrose drain 4. empty a closed drainage system such as a Jackson-Pratt drain or hemovac drain 5. record the output from a closed drainage system such as a Jackson-Pratt drain or hemovac drain

4. empty a closed drainage system such as a Jackson-Pratt drain or hemovac drain 5. record the output from a closed drainage system such as a Jackson-Pratt drain or hemovac drain

a client has clear fluid leaking from the nose following a basilar skull fracture. which finding would alert the nurse that cerebrospinal fluid is present? 1. fluid is clear and tests negative for glucose 2. fluid is grossly bloody in appearance and has a pH of 6 3. fluid clumps together on the dressing and has a pH of 7 4. fluid separates into concentric rings and tests positive for glucose

4. fluid separates into concentric rings and tests positive for glucose

carbidopa-levodopa is prescribed for a client with parkinsons disease. the nurse monitors the client for side and adverse effects of the medication. which finding indicates that the client is experiencing an adverse effect? 1. pruritus 2. tachycardia 3. hypertension 4. impaired voluntary movements

4. impaired voluntary movements

the nurse is planning care for a child with acute bacterial meningitis. based on the mode of transmission of this infection, which precautionary intervention should be included in the plan of care? 1. maintain enteric precautions 2. maintain neutropenic precautions 3. no precautions are required as long as antibiotics have been started 4. maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics

4. maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics

the nurse is assessing a client with a spinal cord injury for the development of deep vein thrombosis. which is the most effective way to determine deep vein thrombosis in this client? 1. detect positive homan's signs 2. rate the amount of pain 3. assess for tenderness 4. measure leg girth

4. measure leg girth

a child is diagnosed with reye's syndrome. the nurse creates a nursing care plan for the child and should include which intervention in the plan? 1. assessing hearing loss 2. monitoring urine output 3. changing body position every 2 hours 4. providing a quiet atmosphere with dimmed lighting

4. providing a quiet atmosphere with dimmed lighting

the client is admitted to the hospital with a diagnosis of GB syndrome. which past medical history finding makes the client most at risk for this disease? 1. meningitis or encephalitis during the last 5 years 2. seizures or trauma to the brain within the last year 3. back injury or trauma to the spinal cord during the last 2 years 4. respiratory or gastrointestinal infection during the previous month

4. respiratory or gastrointestinal infection during the previous month

a nurse is instructing a client who had abdominal surgery that day to do deep breathing exercises. in which order from first to last should the nurse teach the client to perform diaphragmatic breathing and coughing? 1. inhale through the nose 2. cough deeply from the lungs 3. exhale through pursed lips 4. splint the incisional site

4. splint the incisional site 1. inhale through the nose 3. exhale through pursed lips 2. cough deeply from the lungs

after 1 month of therapy, the client in spinal shock begins to experience muscle spasms in the legs and calls the nurse in excitement to report the leg movement. which response by the nurse would be the most accurate? 1. these movements indicate that the damaged nerves are healing 2. this is a good sign. keep trying to move all the affected muscles 3. the return of movement means that eventually you should be able to walk again 4. the movements occur from muscle reflexes that cannot be initiated or controlled by the brain

4. the movements occur from muscle reflexes that cannot be initiated or controlled by the brain

UAP are helping a client who has had knee surgery 2 days ago to get in bed. as the nurse makes rounds, which information requires the nurse to intervene? 1. the call light is pinned to the head of the bed in the client's reach 2. the night light is dimmed, giving low level lighting to the room 3. there is a clear path to the bathroom 4. the side rails on the head of the bed and foot of the bed are in the up position

4. the side rails on the head of the bed and foot of the bed are in the up position

a 9 year old child with GB syndrome requires mechanical ventilation. Which action should the nurse take? 1. Maintain the child in a supine position to prevent unnecessary nerve stimulation 2. Transfer the child to a beside chair three times a day to prevent postural hypotension 3. engage the child in vigorous passive range of motion exercises to prevent loss of muscle function 4. turn the child slowly and gently from side to side to prevent respiratory complications

4. turn the child slowly and gently from side to side to prevent respiratory complications

the nurse has instructed the family of a client with stroke who has homonymous hemianopsia about measures to help the client overcome the deficit. which statement suggests that the family understands the measures to use when caring for the client? 1. we need to discourage him from wearing eyeglasses 2. we need to place objects in his impaired field of vision 3. we need to approach him from the impaired field of vision 4. we need to remind him to turn his head to scan the lost visual field

4. we need to remind him to turn his head to scan the lost visual field

after surgical repair of a myelo. which position should the nurse use to prevent musculoskeletal deformity in the infant? 1. place the feet in flexion 2. allow the hips to abducted 3. maintain knees in the neutral position 4. place the legs in abduction

2. allow the hips to abducted

the client has a sustained increased ICP of 20 mm Hg. which client position would be most appropriate? 1. the head of the bed elevated 15 to 20 degrees 2. trendelenburg's position 3. left sim's position 4. the head elevated on two pillows

1. the head of the bed elevated 15 to 20 degrees

a client is at risk for increased ICP. which finding is the priority for the nurse to monitor? 1. unequal pupil size 2. decreasing systolic blood pressure 3. tachycardia 4. decreasing body temp

1. unequal pupil size

when interviewing the parents of a toddler, the nurse should suspect pneumococcal meningitis if there is a history of which illness? 1. bladder infection 2. middle ear infection 3. fractured clavicle 4. septic arthritis

2. middle ear infection

when planning care for a client with myasthenia gravis, the nurse understands that the client is at highest risk for which health problem? 1. aspiration 2. bladder dysfunction 3. hypertension 4. sensory loss

1. aspiration

parents bring a 10 month old boy with myelomeningocele and hydrocephalus with a ventriculoperitoneal shunt to the ED. his symptoms include vomiting, poor feeding, lethargy, and irritability. what interventions by the nurse are most appropriate? 1. weigh the child 2. listen to the bowel sounds 3. palpate the posterior fontanelle 4. obtain vital signs 5. assess pitch and quality of the child's cry

1. weigh the child 2. listen to the bowel sounds 4. obtain vital signs 5. assess pitch and quality of the child's cry

a child with a brain tumor has a decreased respiratory rate and is less responsive to verbal commands than he was when the nurse assessed the client the previous hour. what should the nurse do next? 1. raise the head of the bed 2. notify the HCP 3. implement seizure precaution 4. obtain an oximeter reading

2. notify the HCP

a client receiving continuous mandatory ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. what should the nurse do? 1. count the rate to be sure that ventilations are deep enough to be sufficient 2. notify the HCP of the client's breathing pattern 3. increase the rate of ventilations 4. increase the tidal volume on the ventilator

2. notify the HCP of the client's breathing pattern

which nursing goal is realistic to establish with a client who has MS? 1. greater joint flexibility 2. improved muscle strength 3. clearer thinking 4. fewer mood swings

2. improved muscle strength

a client with MS lives with her daughter and 3 year old granddaughter. the daughter asks the nurse what she can do at home to help her mother. which measure would be most beneficial? 1. psychotherapy 2. regular exercise 3. day care for the granddaughter 4. weekly visits by another person with MS

2. regular exercise

when caring for a client with GB syndrome, the nurse can delegate which activity to UAP? 1. assess weakness with ROM exercises 2. reposition the client every 2 hours 3. suction the endotracheal tube 4. show the client how to do deep breathing exercises

2. reposition the client every 2 hours

which is not a typical clinical manifestation of MS? 1. double vision 2. sudden bursts of energy 3. weakness in the extemities 4. muscle tremors

2. sudden bursts of energy

the nurse is teaching the parents of a child with myelo. how to prevent urinary tract infections. what information should be included in the plan of care for the child? select all that apply 1. provide meticulous skin care 2. use crede's maneuver to empty the bladder 3. encourage frequent emptying of the bladder 4. assure adequate fluid intake 5. use tight fitting diapers around the meatus

2. use crede's maneuver to empty the bladder 3. encourage frequent emptying of the bladder 4. assure adequate fluid intake

a client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the IV line. what should the nurse do to protect the client without increasing the ICP? 1. place the client in a jacket restraint 2. wrap the hands in soft mitten restraints 3. tuck arms and hands under the sheet 4. apply a wrist restraint to each arm

2. wrap the hands in soft mitten restraints

the nurse is assigned to care for an 8 year old with a diagnosis of a basilar skull fracture. the nurse reviews the pediatricians prescriptions and should contact the pediatrician to question which prescription? 1. obtain daily weight 2. provide clear liquid intake 3. nasotracheal suction as needed 4. maintain a patent IV line

3. nasotracheal suction as needed

a hospitalized preschooler with meningitis who is to be discharged becomes angry when the discharge is delayed. which play activity would be most appropriate at this time? 1. reading the child a story 2. painting with watercolors 3. pounding on a pegboard 4. stacking a tower with blocks

3. pounding on a pegboard

when positioning a neonate with an unrepaired myelo. which position is most appropriate? 1. supine with the hips at 90 degree flexion 2. right side lying position with knees flexed 3. prone with hips in abduction 4. supine in semi fowlers position with the chest and abdomen elevated

3. prone with hips in abduction

a client with MS is receiving baclofen. the nurse determines that the drug is effective when it produces which outcome? 1. induces sleep 2. stimulates the client's appetite 3. relieves muscular spasicity 4. reduces the urine bacterial count

3. relieves muscular spasicity

after a child undergoes a craniotomy for an infratentorial brain tumor, the nurse should place the child in which position to prevent undue strain on the sutures? 1. prone 2. semi fowlers 3. side lying 4. trendelenburg

3. side lying

the nurse is assessing a client for movement after halo traction placement for a C8 fracture. what should the nurse do to test the client's ability to move? ask the client to: 1. shrug shoulders against downward resistance 2. pull arm up from a resting position against resistance 3. straighten arm from a flexed position against resistance 4. grasp the nurse's hands with both hands and squeeze

4. grasp the nurse's hands with both hands and squeeze

a school age child is admitted to the hospital with the diagnosis of probable infratentorial brain tumor. during the child's admission to the pediatric unit, which action should the nurse anticipate taking first? 1. eliminate the child's anxiety 2. implement seizure precautions 3. introduce the child to other clients of the same age 4. prepare the child and parents for diagnostic procedures

4. prepare the child and parents for diagnostic procedures

the nurse teaches an adolescent about returning to school after a concussion. which statement by the client reflects the need for more teaching? 1. I should limit my activities that require conversation 2. I must slowly return to my previous activity level as my symptoms improve 3. my symptoms may reemerge with exertion 4. time is the most important factor in my recovery

4. time is the most important factor in my recovery

a client with a head injury regains consciousness after several days. when the client first awakes, what should then nurse say to the client? 1. I'll get your family 2. can you tell me your name and where you live? 3. I'll bet you're a little confused right now 4. you're in the hospital. you were in an accident and unconscious

4. you're in the hospital. you were in an accident and unconscious

a child who was intubated after a craniotomy now shows signs of decreased level of consciousness. the HCP prescribes manual hyperventilation to the PaCO2 between 25 and 29 and the PaO2 between 80 and 100. the nurse interprets that this action will accomplish which goal? 1. decrease intracranial pressure 2. ensure a patent airway 3. lower the arousal level 4. produce hypoxia

1. decrease intracranial pressure

a 3 month old infant with meningococcal meningitis has just been admitted to the pediatric unit. which nursing intervention has the highest priority? 1. instituting droplet precautions 2. administering acetaminophen 3. obtaining history information from the parents 4. orienting the parents to the pediatric unit

1. instituting droplet precautions

the nurse is monitoring an infant with meningitis for signs of increased intracranial pressure. the nurse should assess the infant for which signs or symptoms? select all that apply 1. irritability 2. headache 3. mood swings 4. bulging fontanelle 5. emesis

1. irritability 4. bulging fontanelle 5. emesis

the nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. which condition does the nurse suspect? 1. meningitis 2. spinal cord injury 3. intracranial bleeding 4. decreased cerebral blood flow

1. meningitis

the nurse is reviewing the medical record of a client who is scheduled for a lumbar laminectomy. the nurse should report which finding to the surgeon? 1. pimple on the lower back 2. abnormal ECG 3. hearing aid 4. allergy to iodine

1. pimple on the lower back

during the acute stage of meningitis a 3 year old child is restless and irritable. which invention would be most appropriate to institute? 1. limiting conversation with the child 2. keeping extraneous noise to a minimum 3. allowing the child to play in the bathtub 4. performing treatments quickly

2. keeping extraneous noise to a minimum

a school aged boy with a spinal cord injury is moved to the rehabilitation unit. the nurse notes that the child tends to refuse to cooperate in care and to be hostile. the interprets this behavior as indicative of which response? 1. a stage of grief reaction 2. a phase of rebellion 3. a reaction to sensory overload 4. a response to too much attention

1. a stage of grief reaction

which sign should lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation? 1. hemorrhagic skin rash 2. edema 3. cyanosis 4. dyspnea in exertion

1. hemorrhagic skin rash

which respiratory pattern indicates increasing ICP in the brain stem? 1. slow, irregular respirations 2. rapid, shallow respirations 3. asymmetric chest excursion 4. nasal flaring

1. slow, irregular respirations

a parent of a child with a moderate head injury asks the nurse "how will you know if my child is getting worse?" the nurse should tell the parents that the best indicator of the child's brain function is which factor? 1. the vital signs 2. level of consciousness 3. reactions of their pupils 4. motor strength

2. level of consciousness

a client who had a serious head injury with increased ICP is to be discharged to a rehabilitation facility. which outcome of rehabilitation would be appropriate for the client? the client will: 1. exhibit no further episodes of short term memory loss 2. be able to return to his construction job in 3 weeks 3. actively participate in the rehab process as appropriate 4. be emotionally stable and display preinjury personality traits

3. actively participate in the rehab process as appropriate

which action should the nurse do first when noting clear drainage on the child's dressing and bed linen after a craniotomy for a brain tumor? 1. change the dressing 2. elevate the head of the bed 3. test the fluid for glucose 4. notify the HCP

3. test the fluid for glucose

nursing care management of the child with bacterial meningitis includes which interventions? select all that apply 1. administration of IV antibiotics 2. IV fluids at 1.5 time maintenance 3. decreasing environmental stimuli 4. neurologic checks every 4 hours 5. administration of IV anticolvulsants

1. administration of IV antibiotics 3. decreasing environmental stimuli 4. neurologic checks every 4 hours

the parents of an infant with myelo. ask the nurse about their childs future mental ability. what is the nurse's best response? 1. about one third have an intellectual disability but it is too early to tell with your child 2. intellectual disabilities occur in about two thirds of these children and you will know soon if this will occur 3. your child probably be of normal intelligence since he shows signs of it now 4. you will need to talk with the HCP about that, but you can ask later

1. about one third have an intellectual disability but it is too early to tell with your child

the nurse is discussing discharge instructions with a client with MG who is taking pyridostigmine. what should the nurse instruct the client to do? 1. administer artificial tears 2. avoid contact with crowds 3. take pyridostigmine in the afternoon 4. decrease protein in the diet

1. administer artificial tears

a school age child with a severe head injury is unconscious and has coarse breath sounds, a temp of 39 C, heart rate 70, BP 130/60, ICP of 36. which action should the nurse take first? 1. administer the prescribed IV mannitol 2. suction the child 3. encourage the parent to talk to the child 4. administer the prescribed acetaminophen

1. administer the prescribed IV mannitol

a NG tube is prescribed to be inserted for a child with severe head trauma. diagnostic testing reveals that the child has a basilar skull fracture. what should the nurse do next? 1. ask for the prescription to be changed to an oral gastric tube 2. attempt to place the tube into the duodenum 3. test the gastric aspirate for blood 4. use extra lubrication when inserting the NG tube

1. ask for the prescription to be changed to an oral gastric tube

an 8 year old child does well after infratentorial tumor removal and is being transferred back to the pediatric unit. although she had been told about having her head shaved for surgery, she is very upset. after exploring the child's feelings, the nurse should take which action? 1. ask the child if she would like to wear a hat 2. reassure the child that her hair will grow back 3. explain to the child's parents that her reaction is normal 4. suggest that the parents buy the child a wig as a surprise

1. ask the child if she would like to wear a hat

the nurse is assessing a child diagnosed with a brain tumor. which signs and symptoms should the nurse expect the child to demonstrate? select all that apply 1. head tilt 2. vomiting 3. polydipsia 4. lethargy 5. increased appetite 6. increased pulse

1. head tilt 2. vomiting 4. lethargy

a client has had MS for 15 years and had received various drug therapies. what is the primary reason why the nurse has found it difficult to evaluate the effectiveness of the drugs that the client has used? the client: 1. exhibits intolerance to many drugs 2. experiences spontaneous remissions from time to time 3. requires multiple drugs spontaneously 4. endures long periods of exacerbation before the illness responds to a particular drug

2. experiences spontaneous remissions from time to time

when assessing the client with MS for potential complications of the disease, the nurse should assess the client for which symptoms? select all that apply 1. dehydration 2. falls 3. seizures 4. skin breakdown 5. fatigue

2. falls 4. skin breakdown 5. fatigue

the nurse is inserting a NG tube in a child admitted with head trauma. the nurse should explain to the parents that the NG tube will be used for which purpose? 1. administer medications 2. decompress the stomach 3. obtain gastric specimens for analysis 4. provide adequate nutrition

2. decompress the stomach

the nurse is teaching a client with bladder dysfunction from MS about bladder training at home. Which instruction should the nurse include in the teaching plan? select all that apply 1. restrict fluids to 1000 mL/hours 2. drink 400 to 500 mL with each meal 3. drink fluids midmorning, midafternoon, and late afternoon 4. attempt to void at least every 2 hours 5. use intermittent catheterization as needed

2. drink 400 to 500 mL with each meal 3. drink fluids midmorning, midafternoon, and late afternoon 4. attempt to void at least every 2 hours 5. use intermittent catheterization as needed

the nurse assigned to telephone triage returns the call of a parent whose teenager experienced a hard tackle last night. the parent reports "he seemed dazed after it happened, and the coach had him sit out the rest of the game but he's fine now." what is the most appropriate instruction for the nurse to give? 1. take him immediately to the ED 2. he can't return to play until he has been evaluated by a HCP 3. if he seems fine now and has had no other symptoms, it was probably not a concussion 4. watch him closely, and call us back if you see any changes

2. he can't return to play until he has been evaluated by a HCP

the nurse is preparing a client with MS for discharge from the hospital to home. what information should the nurse include in the teaching plan? 1. you'll need to accept the necessity for a quiet and inactive lifestyle 2. improved muscle strength 3. follow good health habits to change the course of the disease 4. practice using the mechanical aids that you'll need when future disabilities arise

2. improved muscle strength

assessment of a school age child with GB syndrome reveals absent gag and cough reflexes. Which problem should receive the highest priority during the acute phase? 1. impaired physical mobility related to paralysis 2. ineffective breathing pattern related to neuromuscular impairment 3. impaired swallowing related to neuromuscular impairment 4. fluid volume deficits related to total urinary incontinence

2. ineffective breathing pattern related to neuromuscular impairment

the nurse administers mannitol to the client with increased ICP. which parameter requires close monitoring? 1. muscle relaxation 2. intake and output 3. widening of the pulse pressure 4. pupil dilation

2. intake and output

A nurse, who witnesses an accident involving an adolescent being thrown from a motorcycle, stops to help. the adolescent reports that he is now unable to move his legs. while waiting for the emergency medical service to arrive, what should the nurse do? 1. flex the adolescent's knees to relieve stress on his back 2. leave the adolescent as he is, staying close by 3. remove the adolescent's helmet as soon as possible 4. assess the adolescent for abdominal trauma

2. leave the adolescent as he is, staying close by

a preschooler with pneumococcal meningitis is receiving IV antibiotic therapy. when discontinuing the IV therapy, the nurse allows the child to apply the dressing to the area where the catheter is removed. the nurse's rationale for doing so is based on the interpretation that a child in this age group has a need to accomplish which goal? 1. trust those who care for her 2. find diversional activities 2. middle ear infection 4. relieve the anxiety of separation from home

2. middle ear infection

the HCP has prescribed IV mannitol for a child with a head injury. the best indicator that the drug has been effective is which assessment finding? 1. increased urine output 2. improved level of consciousness 3. decreased intracranial pressure 4. decreased edema

3. decreased intracranial pressure

a client has an increased ICP of 20 mm Hg. what should the nurse do next? 1. give the client a warming blanket 2. administer low dose barbiturates 3. encourage the client to take deep breaths to hyperventilate 4. restrict fluids

3. encourage the client to take deep breaths to hyperventilate

which intervention should the nurse suggest to help a client with MS avoid episodes of urinary incontinence? 1. limit fluid intake to 1000 mL/day 2. insert an indwelling urinary catheter 3. establish a regular voiding schedule 4. administer prophylactic antibiotics as prescribed

3. establish a regular voiding schedule

a 3 year old is recovering from a concussion. the persistence of which finding would the nurse consider as being a normal finding for a 3 year old? 1. lack of interest in favorite toys 2. change in eating habits 3. inability to hop 4. increased temper tantrums

3. inability to hop

The nurse asks a school age child with GB syndrome to cough and also assesses the child's speech for decreased volume and clarity. The underlying rationale for these assessments is to determine which finding? 1. inflammation of the larynx and epiglottis 2. increased intracranial pressure 3. involvement of facial and cranial nerves 4. regression to an earlier developmental phase

3. involvement of facial and cranial nerves

a young adult is admitted to the hospital with a head injury and a possible temporal skull fracture sustained in a motorcycle accident. on admission the client was conscious but lethargic. temp 99 F, pulse 100, respirations 18, BP 140/70. the nurse should report which changes should they occur to the HCP? select all that apply 1. decreasing urinary output 2. decreasing systolic BP 3. bradycardia 4. widening pulse pressure 5. tachycardia 6. increasing systolic BP

3. bradycardia 4. widening pulse pressure

what should the nurse do first when a client with a head injury begins to have clear drainage from the nose? 1. compress the nares 2. tilt the head back 3. collect the drainage 4. administer an antihistamine for post nasal drip

3. collect the drainage

the parents of a child in a coma with a serious head injury ask the nurse if the child is going to be alright. which response by the nurse would be most appropriate? 1. children usually do not do very well after head injuries like this 2. children usually recover rapidly from head injuries 3. it is hard to tell this early but we will keep you informed of the progress 4. that is something you will have to talk to the HCP about

3. it is hard to tell this early but we will keep you informed of the progress

an adolescent client has seen the school nurse several times with headache, vomiting, and difficulty walking. when calling the adolescent's mother about these symptoms, the nurse should suggest the mother do what first? 1. schedule an appointment with the eye HCP 2. begin psychological counseling for her adolescent 3. make an appointment with the adolescent's HCP 4. meet with the adolescent's teachers to determine academic progress

3. make an appointment with the adolescent's HCP

during assessment of an adolescent who has sustained a recent thoracic spinal injury, the nurse auscultates the adolescent's abdomen. the nurse explains to the parents that this is necessary because clients with spinal cord injury often develop which problem? 1. abdominal cramping 2. hyperactive bowel sounds 3. paralytic ileus 4. profuse diarrhea

3. paralytic ileus

the nurse is reviewing the record of a child with increased ICP and notes that he child has exhibited signs of decerebrate posturing. on assessment of the child, the nurse expects to note which characteristic of this type of posturing? 1. flaccid paralysis of all extremities 2. adduction of the arms at the shoulders 3. rigid extension and pronation or the arms and legs 4. abnormal flexion of the upper extremities and extension of adduction of the lower extremities

3. rigid extension and pronation or the arms and legs

after receiving a change of shift report at 0700 the nurse should assess which client first? 1. 23 year old with a migraine headache who has severe nausea associated with retching 2. 45 year old who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching 3. 59 year old with parkinsons disease who will need a swallowing assessment before breakfast 4. 63 year old with MS who has an oral temp of 101.8 F and flank pain

4. 63 year old with MS who has an oral temp of 101.8 F and flank pain

When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing intervention is contraindicated? 1. Encouraging the client to speak slowly. 2. Encouraging the client to speak distinctly. 3. Asking the client to repeat indistinguishable words. 4. Asking the client to speak louder when tired.

4. Asking the client to speak louder when tired.

a client has delirium following a head injury. the client is disoriented and agitated. in which order from first to last should the nurse initiate care for this client? 1. request a prescription for haloperidol 2. maintain a quiet environment 3. assure the clients safety 4. approach the client using short sentences

4. approach the client using short sentences 3. assure the clients safety 2. maintain a quiet environment 1. request a prescription for haloperidol

the nurse is assessing a clients motor response after brain surgery. the nurse pinches the clients skin to elicit a response and observes the client's arms and legs moving straight out and the feet and toes bend downward. how should the nurse document this response? 1. flaccid paralysis 2. flexion posturing 3. chronic spastic paralysis 4. extension posturing

4. extension posturing

which information should the nurse include in the discharge plan for a client with MS who has an impaired peripheral sensation? select all that apply 1. carefully test the temperature of bath water 2. avoid kitchen activities because of the risk of injury 3. avoid hot water bottles and heating pads 4. inspect the skin daily for injury or pressure points 5. wear warm clothing when outside in cold temperatures

1. carefully test the temperature of bath water 3. avoid hot water bottles and heating pads 4. inspect the skin daily for injury or pressure points 5. wear warm clothing when outside in cold temperatures

two months after an adolescent's thoracic spinal cord injury, he has a pounding headache. the nurse notes that the client's arms and face are flushed and he is diaphoretic. what should the nurse do next? 1. check the patency of the urinary catheter 2. lower the adolescent's head below the knees 3. place the adolescent flat on his back 4. prepare to administer epinephrine subcutaneously

1. check the patency of the urinary catheter

an adolescent sustains a T3 spinal cord injury. after insertion of an IV line, a NG tube, and an indwelling urinary catheter, the adolescent is admitted to the ICU. What should the nurse do next when the assessment reveals the adolescent's feet and legs are cool to the touch? 1. cover the adolescent's legs with blankets 2. report the finding to the HCP immediately 3. reposition the adolescent's legs 4. lay the adolescent flat to aid circulation

1. cover the adolescent's legs with blankets

Which assessment would be most important for the nurse to make initially in a school age child being seen in the clinic who has a sore throat, muscle tenderness, arms feeling weak, and generally is not feeling well? 1. difficulty swallowing 2. diet intake for the last 24 hours 3. exposure to illnesses 4. difficulty urinating

1. difficulty swallowing

when developing the plan of care for an infant with myelo. and the parents have been informed of the infants diagnosis, the nurse should include which action as the priority when the parents visit the infant for the first time? 1. emphasize the infants normal and positive features 2. encourage the parents to discuss their fears and concerns 3. reinforce the HCP's explanation of the defect 4. have the parents feed their infant

1. emphasize the infants normal and positive features

the nurse is caring for a preschool aged client with a neuroblastoma who has been receiving chemo for the last 4 weeks. his lab results indicate an Hgb of 12.5 g/dL, an HCT of 36.8%, WBC of 2,000 mm, platelet count of 100,000. based on the child's lab values, what is the highest priority nursing intervention? 1. encourage meticulous handwashing by the client and visitors 2. prepare to give the child a transfusion of platelets 3. encourage mouth care with a small toothbrush 4. prepare to give the child a transfusion of packed red blood cells

1. encourage meticulous handwashing by the client and visitors

the mother of an infant with myelo. asks if her baby is likely to have any other defects. the nurse responds based on the understanding that myelo. is commonly associated with which disorder? 1. excessive cerebrospinal fluid within the cranial cavity 2. abnormally small head 3. congenital absence of the cranial vault 4. overriding of the cranial sutures

1. excessive cerebrospinal fluid within the cranial cavity

the nurse is planning care for a client who is at low risk for falling. what information would be included in the care plan? select all that apply 1. place call bell within easy reach 2. secure locks on beds, stretchers, and wheel chairs 3. remain with the client during toileting 4. keep the bed in the lowest position when possible 5. place a commode next to the bed for easy access 6. employ a seat belt whenever a wheelchair is in use

1. place call bell within easy reach 2. secure locks on beds, stretchers, and wheel chairs 4. keep the bed in the lowest position when possible

the nurse is monitoring a client with ICP. what indicators are the most critical for the nurse to monitor? select all that apply 1. systolic blood pressure 2. urine output 3. breath sounds 4. cerebral perfusion pressure 5. level of pain

1. systolic blood pressure 4. cerebral perfusion pressure

Which action should be the priority when caring for a school age child admitted to the pediatric unit with the diagnosis of Guillain-Barre syndrome? 1. assess the child's ability to follow simple commands 2. evaluate the child's bilateral muscle strength 3. make a game of the range of motion exercises 4. provide the child with a diversional activity

2. evaluate the child's bilateral muscle strength

a client with a contusion has been admitted for observation following a motor vehicle accident when he was driving his pregnant wife to the hospital. the next morning, instead of asking about his wife and baby, he asked to see the football game on TV that he thinks is gonna start in 5 minutes. he is agitated because the nurse will not turn on the TV. what should the nurse do next? select all that apply 1. find a TV so the client can view the football game 2. determine if the client's pupils are equal and react to light 3. ask the client if he has a headache 4. arrange for the client to be with his wife and baby 5. administer a sedative

2. determine if the client's pupils are equal and react to light 3. ask the client if he has a headache

the nurse has established a goal to maintain ICP within the normal range for a client who had a craniotomy 12 hours ago. what should the nurse do? select all that apply 1. encourage the client to cough to expectorate secretions 2. elevate the head of the bed 15 to 20 degrees 3. contact the HCP if ICP is >28 mm Hg 4. monitor neurologic status using the glasgow coma scale 5. stimulate the client with active range of motion exercises

2. elevate the head of the bed 15 to 20 degrees 3. contact the HCP if ICP is >28 mm Hg 4. monitor neurologic status using the glasgow coma scale

the nurse is planning the care for a client who has had a posterior fossa craniotomy. what should the nurse avoid when positioning the client? 1. keeping the client flat on one side or other 2. elevating the head of the bed to 30 degrees 3. logrolling or turning as a unit when turning 4. keeping the neck in a neutral position

2. elevating the head of the bed to 30 degrees

the nurse is assessing a client with a head injury for decerebrate posturing. which position indicates the client has decerebrate posturing? 1. internal rotation and adduction of arms with flexion of elbows wrists, and fingers 2. back hunched over and rigid flexion of all four extremities with supination of arms and plantar flexion of feet 3. supination of arms and dorsiflexion of the feet 4. back arched and rigid extension of all four extremities

4. back arched and rigid extension of all four extremities

a mother arrives at the ED with her 5 year old child and states that the child fell off a bunk bed. a head injury is suspected. the nurse checks the child's airway status and assesses the child for early and late signs of increased ICP. which is a late sign of increased ICP? 1. nausea 2. irritability 3. headache 4. bradycardia

4. bradycardia

which activity should the nurse encourage the client to avoid when there is a risk for ICP? 1. deep breathing 2. turning 3. coughing 4. passive ROM exercises

3. coughing