Neurosensory and Musculoskeletal ATI

RN reviewing postoperative instructions with a client following cataract surgery. Which of the following client statements indicates an understanding of instructions? A. I should call my doctor if I experience a decrease in vision B. I may take aspirin for eye discomfort following the surgery C. I can blow my nose to clear out any drainage D. I can lift objects up to 20 pounds

A. I should call my doctor if I experience a decrease in vision -Aspirin should be avoided because it can cause bleeding in the eye -Shouldn't blow nose because it can increase intraocular pressure -Lifting objects heavier than 10 pounds can cause an increase in intraocular pressure

RN planning care for a client who has a closed head injury from a fall and is receiving mechanical ventilation. Which of the following is the nurse's priority? A. Maintain a PaCO2 of approximately 35 mm Hg. B. Provide small doses of fentanyl via IV bolus for pain management C. Monitor body temp every 1 to 2 hr D. Reposition client every 2 hr

A. Maintain a PaCO2 of approximately 35 mmHg. Greatest risk to client is increased intracranial pressure. Want to prevent hypercarbia and subsequent vasodilation effects that lead to increase in intracranial pressure .

RN developing teaching plan for a client with Meniere's disease. Which of the following instructions should the nurse include? A. Move head slowly to decrease vertigo B. Apply warm packs to the affected ear during acute attacks C. Increase intake of foods and fluid high in salt D. Administer corticosteroids during acute attacks

A. Move head slowly to decrease vertigo -C would cause an exacerbation. Want to avoid consuming foods and fluids with high salt content because they can cause fluid retention. -Corticosteroids won't help and can cause further fluid retention. Client should take an antihistamine.

RN in ED caring for a client with embolic stroke. Which of the following meds should the nurse administer? A. Recombinant tissue plasminogen activator B. Recombinant factor VIII C. Nitroglycerin D. Lidocaine

A. Recombinant tissue plasminogen activator Recombinant factor VII used to manage symptoms of hemophilia Lidocaine antidysrhthmic agent used to treat ventricular dysrhythmias

RN in the ED is assessing client with myasthenia graves. Client reports increasing muscle weakness and RN suspects a myasthenic crisis. Which of the following is the priority? A. Administer artificial tears B. Assist with Tensilon test C. Administer immunosuppressants D. Assist with plasmapheresis

B. Assist with Tensilon test -Assessment comes first. This test determines if the client is experiencing a myasthenia crisis or cholinergic crisis. -Should administer artificial tears because client may have dry eyes if they aren't able to close eyes completely, but not priority -Should administer immunosuppressants, but not the priority -Should assist with plasmapheresis to reduce manifestations of myasthenia crisis, but not priority

RN providing teaching for client prescribed alendronate for osteoporosis. Which of the following should the RN include in the teaching? A. Take med with 240 cc of milk B. Remain upright for 30 minutes after taking the med C. Expect the med to increase serum calcium levels D. Increase Vitamin D intake to promote med absorption

B. Remain upright for 30 minutes after taking the med -This prevents esophagitis that can result. -The med should be taken with 240 cc of water -The med is a biphosphonate which combines with bone tissue to prevent bone resorption. It can decrease serum calcium level

RN caring for a client who is 8 hr postoperative following a craniotomy. Which of the following actions should the RN take? A. Suction the client every 2 hr B. Report wound drainage greater than 50 cc/8 hr C. Position the client flat in bed D. Assess the client's neuro status every 8 hr

B. Report wound drainage greater than 50 cc/8 hr -Client is at risk for hemorrhage and hypovolemic shock. Would only suction when necessary (can cause increased ICP)

RN assessing a client with RA. Which of the following assessment findings should the RN expect? A. Unilateral joint involvement B. Ulnar deviation C. Fractures of the pie D. Decreased sedimentation rate

B. Ulnar deviation -Inflammation in the hand joints can make them susceptible to deformity. -RA occurs bilaterally and symmetrically. -Compression fractures of spine are more likely in osteoporosis. -Increased sedimentary rate due to body's response to inflammatory connective tissue disorder

RN planning care for a client following a lumbar puncture. Which of the following actions should the nurse plan to include? A. Apply a pressure dressing to the site for 12 hours B. Restrict client's fluid intake for 24 hr C. Ensure the client lies flat for 4 to 8 hr D. Administer pain med every 3 to 4 hr

C. Ensure the client lies flat for 4 to 8 hr -Prevents CSF leakage from site -Fluid intake should be increased to reduce risk of a headache -Only a single dose analgesic may be required

RN caring for a client with retinal detachment. Which of the following reports about the affected eye should the nurse expect? A. Photophobia B. Complete blindness C. Flashes of bright light D. Pain

C. Flashes of bright light -Or floating dark spots

RN 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? A. I should expect slight increase in my BP while taking this med B. I should take my med with a high-protein food C. I should expect my urine to be a darker color D. I will expect it to take up to a week for this med to work

C. I should expect my urine to be a darker color -Secretions such as saliva, urine, and sweat can darken in color on this med. -Adverse effect is orthostatic hypotension. -High protein foods can delay the absorption -It can take weeks to months for this med to take effect

RN caring for client with multiple sclerosis. Which of the following findings should the RN expect? A. Hypoactive deep-tendon reflexes B. Ascending paralysis C. Intention tremors D. Increased lacrimation

C. Intention tremors Also at risk for poor coordination and loss of balance (motor dysfunction) -Have hyperactive DTRs. -Ascending paralysis is Guillain-Barre syndrome -Increased lacrimation in myasthenia graves

RN caring for a client who has advancing ALS. Which of the following is the priority? A. Provide for frequent rest periods throughout the day B. Medicate for pain on a regular schedule C. Monitor pulse oximetry findings D. Administer baclofen for spasticity

C. Monitor pulse oximetry findings -Greatest risk to client is respiratory compromise due to progressive paralysis of respiratory muscles. The others the nurse would also do, but not the priority

RN assessing a client who is quadriplegic secondary to a cervical fracture at C5. Client reports throbbing headache and nausea. RN notes facial flushing and a BP of 220/110 mmHg. Which of the following should the RN take first? A. Administer hydralazine via IV bolus B. Loosen client's clothing C. Empty the client's bladder D. Elevate the HOB

D. Elevate the HOB -Client is at greatest risk for autonomic dysreflexia and possible rupture of a cerebral vessel or increased ICP. Elevating HOB will decrease BP

RN caring for a client who is recovering from a stroke and has right-sided homonymous hemianopsia. TO help the client adapt, the RN should take which of the following actions? A. Check the client's cheek on his affected side after eating to be sure no food remains there B. Encourage the client to sit upright with his head tilted slightly forward during meals C. Provide the client with eating utensils that have large handles D. Remind the client to look consciously at both sides of his meal tray

D. Remind the client to look consciously at both sides of his meal tray -Homonymous hemianopsia has lost the right visual field of both eyes; might only eat the meal able to see on the left half of meal tray.