NEURO/MSK

A nurse is caring for a client who has a spastic bladder following a spinal cord injury. Which of the following actions should the nurse take to help stimulate micturition?

Stroke the client's inner thigh. - antispasmodics

A nurse is assessing a client who has a new diagnosis of osteoarthritis. Which of the following findings should the nurse expect? (Select all that apply.)

Crepitus with joint movement is correct. Crepitus, a grating sound, is an expected finding of osteoarthritis as loosened bone and cartilage move in the diseased joint. Decreased range of motion of the affected joint is correct. Decreased range of motion is an expected finding of osteoarthritis because the client's pain limits movement. Involvement of smaller joints of the body is incorrect. Osteoarthritis affects larger joints, such as the hips and knees. Spongy tissue over the joints is incorrect. Spongy joint tissue is an expected finding of rheumatoid arthritis, which is an inflammatory disease. Joint pain that resolves with rest is correct. Clients who have osteoarthritis have increased pain with activity and decreased pain with rest.

A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect?

Impulsive behavior, poor judgement, lack of awareness of deficits, l sided neglect - L hemi: difficulties reading d/t can't discriminate letters and words, aphasia

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect?

Intention tremors hyperactive DTRs

A nurse is caring for a client who has viral meningitis. Which of the following actions should the nurse take?

Monitor capillary refill at least every 4 hr. (complete neuro assessment + VS Q4) - standard precautions only - minimize exposure to light (photophobia can occur)

A nurse is developing a teaching plan for a client who has Ménière's disease. Which of the following instructions should the nurse include?

Move head slowly to decrease vertigo. - avoid high salt --> fluid retention --> exacerbates manifestations of MD; also antihistamines (meclizine) to avert attack; NO corticosteroids!!

A nurse is providing teaching for a client who is prescribed alendronate for osteoporosis. Which of the following information should the nurse include in the teaching?

Remain upright for 30 min after taking this medication and remain sitting until after eating first meal of the day - take with 8oz of WATER (Ca reduces absorption) - biophosphonates combine with bone tissue to prevent bone reabsorption- decrease Sr Ca

A nurse is caring for a client who is recovering from a stroke and has right-sided homonymous hemianopsia. To help the client adapt, the nurse should take which of the following actions?

Remind the client to look consciously at both sides of his meal tray. - has lost right visual field of both eyes, night only eat food on L side of tray

A nurse is teaching a client who has epilepsy and is to start therapy with phenytoin. Which of the following instructions should the nurse include in the client's medication teaching plan?

Take medications at a consistent time each day to maintain therapeutic blood levels. - gingival hyperplasia possible- good oral hygiene! need dental floss and gum massage - stop taking phenytoin + tell HCP if rash develops - DO NOT abruptly d/c phenytoin even if no SZs

A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which of the following interventions is the nurse's priority?

The greatest risk to the client is respiratory compromise due to progressive paralysis of respiratory muscles. Therefore, the priority intervention is to monitor oxygen saturation to identify respiratory compromise as soon as possible. - also need frequent rest periods throughout day - pain meds regularly - baclofen to manage spasticity that interferes with self care

A nurse is providing teaching for a client who is postoperative following a right hip arthroplasty. Which of the following images indicates the position the nurse should teach the client to take when sitting in a chair?

The nurse should teach the client to sit with the hips at a 90° angle or less with the knees slightly lower than the hips to avoid hip dislocation (no leaning over, folding legs, ect)

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

Ulnar deviation - inflammation in hand joints can make them susceptible to deformity from daily use (opening jars) - bilaterally, symmetrically - increaSED ESR

A nurse is reviewing postoperative instructions with a client following cataract surgery. Which of the following client statements indicates an understanding of instructions?

"I should call my doctor if I experience a decrease in my vision." - NO ASA, nose blowing, lifting > 10 lbs

A nurse is providing teaching regarding a new prescription for carbidopa-levodopa for a client who has Parkinson's disease. Which of the following client statements indicates an understanding of the teaching?

"I should expect my urine to be a darker color." + saliva, sweat - orthostatic hypotension -not with high protein foods - may take weeks - months to take effect

A nurse is caring for a client who has a full arm cast and reports pain of 8 on a scale from 0 to 10 that is unrelieved by pain medication. Which of the following actions should the nurse plan to take first?

Check the circulation of the affected extremity. (compartment syndrome!)

A nurse is caring for a client in balanced suspension skeletal traction who reports intermittent muscle spasms. Which of the following actions should the nurse take first?

Check the position of the weights and ropes. - could also give distraction, reposition, muscle relaxant

A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider?

Clear drainage from nose (indicates CSF leaking from skull fracture!!) --> risk for meningeal infection

A nurse is assessing a client who is quadriplegic secondary to a cervical fracture at vertebral level C5. The client reports a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/110 mm Hg. Which of the following actions should the nurse take first?

Elevate the head of the client's bed. --> rapid postural hypotension (good)-- indicates risk for autonomic dysreflexia and poss rupture of cerebral vessel or increased ICP - also good: empty bladder (full bladder or fecal impaction is a trigger for AD), loosen clothing bc body tem and tactile stimulation are triggers for AD, can also give antiHTN

A nurse is planning care for a client following a lumbar puncture. Which of the following actions should the nurse plan to include?

Ensure the client lies flat for 4 to 8 hr. -- prevent CSF fluid leakage - increase fluid intake post

A nurse is caring for a client who was admitted for status epilepticus and is on seizure precautions. Which of the following actions should the nurse plan to take?

Establish IV access.

A nurse in the emergency department is caring for a client after suddenly losing consciousness and falling in her home. The provider determines the client had an embolic stroke. Which of the following medications should the nurse administer?

Recombinant tissue plasminogen activator - dissolves blood clot that caused stroke

A nurse is assessing a client who has a possible head injury following a motor-vehicle crash. The nurse should recognize that which of the following findings indicates increasing intracranial pressure?

Restlessness/irritability = early SSXs - cushing reflex (HTN, widening pulse pressure) = late manifestation

A nurse working in the emergency department is caring for a client who has sustained a fracture of the femur following a motor-vehicle crash. Which of the following images indicates a comminuted fracture?

This is an image of a comminuted fracture, in which the injury causes the bone to fragment into several pieces.

A nurse is providing teaching for a client and his family about the diagnosis and treatment of Alzheimer's disease. Which of the following statements by the family indicates an understanding of the teaching?

"The drugs used to treat Alzheimer's disease can help delay cognitive changes." - enhance availability of acetycholine --> greater response from cholinergic neurons in the brain - DX is by r/o all other diseases - early SXs: short term memory loss, forgetfulness, shortened attention span -

A nurse is planning care for a client who has a closed head injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurse's priority?

Maintain a PaCO2 of approximately 35 mm Hg. --> prevent hypercarbia -> vasodilation --> increased ICP!!!

A nurse in the emergency department is assessing a client who reports sudden, severe eye pain with blurred vision. The provider determines the client has primary angle-closure glaucoma. Which of the following medications should the nurse administer?

Osmotic diuretics via IV bolus-- reduce IOP

A nurse is caring for a client who is 8 hr postoperative following a craniotomy. Which of the following actions should the nurse take?

Report wound drainage greater than 50 mL/8 hr. - suction PRN d/t increased ICP -for supratentorial surgery: elevate HOB to 30 to decrease ICP and keep neutral to promote venous return - for inratentorial surgery: HOB flat and turn client side to side

A nurse in the emergency department is assessing a client who has myasthenia gravis. The client reports recent increasing muscle weakness and the nurse suspects the client is experiencing a myasthenic crisis. Which of the following actions is the nurse's priority?

The first action the nurse should take using the nursing process is to assess the client. The Tensilon test will determine if the client is experiencing a myasthenic crisis or a cholinergic crisis. - also good: artificial tears, immunosuppressants, plasmapheresis

A nurse is caring for a client who is 72 hr postoperative following an above-the-knee amputation and reports phantom limb pain. Which of the following actions should the nurse take?

Administer an oral dose of gabapentin to the client.

A nurse is caring for a client who has a retinal detachment. Which of the following reports about the affected eye should the nurse expect?

During retinal detachment, the client can experience flashes of bright light or floating dark spots in the affected eye as the retinal layers separate. - also SOME visual field loss