Neurosensory/Musculoskeletal Practice Assessment

A nurse is reviewing postoperative instructions with a client following cataract surgery. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I should call my doctor if my vision gets worse." B. "I will take aspirin for eye discomfort." 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 my vision gets worse."The client should report negative changes in vision immediately because there should be an improvement in vision after the surgery. "I will take aspirin for eye discomfort."The client should avoid aspirin because it can cause bleeding in the eye. "I can blow my nose to clear out any drainage."The client should avoid blowing his nose because it can increase intraocular pressure. "I can lift objects up to 20 pounds."The client should avoid lifting objects heavier than 4.5 kg (10 lb) because it can increase intraocular pressure.

A nurse is developing a teaching plan for a client who has Ménière's disease. Which of the following instructions should the nurse include? A. "Move your head slowly to decrease vertigo." B. "Apply warm packs to the affected ear during acute attacks." C. "Increase your intake of foods and fluids high in salt." D. "Take corticosteroids during acute attacks."

A. "Move your head slowly to decrease vertigo."The client should use slow head movements to keep from worsening the vertigo. "Apply warm packs to the affected ear during acute attacks."Applying warm packs to the affected ear does not relieve the manifestations of Ménière's disease. Helpful interventions include drinking plenty of water, decreasing salt intake, and not smoking. "Increase your intake of foods and fluids high in salt."Clients who have Ménière's disease should avoid consuming foods and fluids that have a high sodium content because they cause fluid retention, which exacerbates the manifestations of Ménière's disease. "Take corticosteroids during acute attacks."Taking corticosteroids will not relieve the manifestations of Ménière's disease and can actually worsen them because these medications cause fluid retention. The client should take an antihistamine, such as meclizine, to minimize or stop the attack.

A nurse in an emergency department is assessing a client who reports sudden, severe eye pain with blurry vision. The provider determines that the client has primary angle-closure glaucoma. Which of the following medications should the nurse administer? A. Osmotic diuretics via IV bolus B. Mydriatic ophthalmic drops C. Corticosteroid ophthalmic drops D. Epinephrine via IV bolus

A. Osmotic diuretics via IV bolus. The nurse should administer osmotic diuretics, such as mannitol, to reduce intraocular pressure and prevent damage to the eye. Clients who have primary angle-closure glaucoma should not receive mydriatic ophthalmic drops because they cause pupillary dilation. Instead, the nurse should administer medications that decrease intraocular pressure by increasing the absorption or decreasing the production of aqueous humor. Corticosteroid ophthalmic drops are used for inflammatory conditions of the eye, such as conjunctivitis. There is no indication for clients who have primary angle-closure glaucoma to receive corticosteroid ophthalmic drops. Instead, the nurse should administer medications that decrease intraocular pressure by increasing the absorption or decreasing the production of aqueous humor. Clients who have primary angle-closure glaucoma should not receive epinephrine-containing medications because they cause vasoconstriction. Instead, the nurse should administer medications that decrease intraocular pressure by increasing the absorption or decreasing the production of aqueous humor.

A nurse in an emergency department is caring for a client who suddenly lost consciousness and fell in her home. The provider determines that the client had an embolic stroke. Which of the following medications should the nurse administer? A. Tissues plasminogen activator B. Recombinant factor VIII C. Nitroglycerin D. Lidocaine

A. Tissues plasminogen activator. Tissue plasminogen activator is a thrombolytic agent that should dissolve the blood clot that caused the stroke. Recombinant factor VIII helps manage the manifestations of hemophilia. Nitroglycerin is a coronary and venous vasodilator that treats angina. Lidocaine is an antidysrhythmic agent that treats ventricular dysrhythmias.

A nurse is teaching a client who has osteoporosis and a new prescription for alendronate. Which of the following information should the nurse include in the teaching? A. "Take the medication with 240 mL of milk." B. "Remain upright for 30 min after taking this medication." C. "Expect the medication to cause insomnia." D. "Take vitamin C to promote medication absorption."

B. "Remain upright for 30 min after taking this medication."To prevent esophagitis or esophageal ulcers that can result from alendronate therapy, the client should sit up for 30 min after taking this medication. "Take vitamin C to promote medication absorption." Vitamin C intake does not increase alendronate absorption and some sources, such as orange juice, decrease absorption. However, the nurse should encourage the client to take vitamin D, which promotes calcium absorption. Expect the medication to cause insomnia." Alendronate does not cause insomnia. Headache is a common adverse effect of alendronate. "Take the medication with 240 mL of milk." The nurse should instruct the client to take alendronate with 240 mL (8 oz) of water, not milk. Foods or beverages containing calcium can reduce medication absorption.

A nurse is assessing a client who has rheumatoid arthritis. Which of the following assessment findings should the nurse expect? A. Unitlateral joint involvement B. Ulnar deviation C. Fractures of the spine D. Decreased sedimentation rate

B. Ulnar deviation The inflammation that occurs in the hand joints can make them susceptible to deformity from daily use. Ulnar deviation, or lateral deviation of the fingers, can occur from opening jars and other similar motions. Rheumatoid arthritis usually occurs bilaterally and symmetrically. Osteoarthritis usually occurs unilaterally. Compression fractures of the spine are more common in clients who have osteoporosis. Decreased sedimentation rate The client who has rheumatoid arthritis will have an increased sedimentation rate due to the body's response to the inflammatory connective tissue disorder.

A nurse is caring for a client who has viral meningitis. Which of the following actions should the nurse take? A. Assess the client's neurologic status every 8 hr B. Initiate droplet precautions C. Check capillary refill at least every 4 hr D. Place the client in a well-lit environment

C. Check capillary refill at least every 4 hr. The nurse should perform a complete vascular assessment at least every 4 hr to monitor for vascular compromise. Assess the client's neurologic status every 8 hr. The nurse should assess the client's vital signs and neurologic status at least every 2 to 4 hr. Initiate droplet precautions.The nurse should implement droplet precautions for clients who have bacterial meningitis. Standard precautions are sufficient for clients who have viral meningitis. Place the client in a well-lit environment. The nurse should minimize the client's exposure to light from windows and overhead lights because photophobia, or light sensitivity, is a manifestation of viral meningitis.

A nurse is caring for a client who has retinal detachment. Which of the following client 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

A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect? A. Aphasia B. Right-sided neglect C. Impulsive behavior D. Inability to read

C. Impulsive behavior

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? A. Hypoactive deep-tendon reflexes B. Ascending paralysis C. Intention tumors D. Increased lacrimation

C. Intention tumors. Clients who have multiple sclerosis are at risk for motor dysfunction, with intention tremors, poor coordination, and loss of balance. Increased lacrimation Increased lacrimation, or tearing of the eyes, is an expected finding of myasthenia gravis during a cholinergic crisis. Ascending paralysis Clients who have Guillain-Barré syndrome are at risk for ascending paralysis. Hypoactive deep-tendon reflexes Clients who have multiple sclerosis have hyperactive deep-tendon reflexes.

A nurse is teaching a client and his family about the diagnosis and treatment of Alzheimer's disease. Which of the following statements should the nurse identify as an indication that the family understands the teaching? A. "There is a test for Alzheimer's disease that can establish a reliable diagnosis." B. "The goal of medication therapy is to revers the degenerative changes that can occur in brain tissue." C. "Early manifestations of Alzheimer's disease include mild tremors and rigidity." D. "The medications that treat Alzheimer's disease can help delay cognitive changes."

D. "The medications that treat Alzheimer's disease can help delay cognitive changes." Medications that treat Alzheimer's disease enhance the availability of acetylcholine, which can slow cognitive decline in some clients. Early manifestations include short-term memory loss, forgetfulness, and a shortened attention span. Mild tremors and muscular rigidity are manifestations of Parkinson's disease. None of the medications currently available reverse the course of Alzheimer's disease .There is no specific test for identifying Alzheimer's disease, except direct examination of the brain on autopsy. Providers diagnose Alzheimer's disease based on manifestations and by ruling out other diseases.

A nurse is caring for a client who has a history of status epilepticus and requires seizure precautions. Which of the following actions should the nurse take? A. Assess hourly for a spike in blood pressure B. Keep the client on bed rest C. Keep a padded tongue blade at the bedside D. Establish IV access

D. Establish IV access. The nurse should plan to establish IV access with a large-bore catheter and administer 0.9% sodium chloride if seizures are imminent. If the client is stable, the nurse should initiate a saline lock. The nurse should not plan to place objects, such as a padded tongue blade, in the client's mouth during a seizure because it can injure her teeth and put her at risk for aspirating tooth fragments. The tongue blade could also obstruct her airway. A client at risk for seizures does not require bed rest. However, if seizures are imminent or frequent, the nurse should institute safety measures, such as placing the mattress on the floor or raising the side rails, according to agency policy. The nurse should check the client's vital signs and perform neurological checks after a seizure. However, a change in blood pressure does not correlate with an increased incidence of seizure activity.

A nurse is assessing a client who has a head injury following a motor-vehicle crash. The nurse should identify that which of the following findings indicates increasing intracranial pressure? A. Restlessness B. Dizziness C. Hypotension D. Fever

Restlessness. Behavioral changes, such as restlessness and irritability, are early manifestations of increased intracranial pressure. Although dizziness might be present after head trauma, it is not a manifestation of increased intracranial pressure. Hypotension Although hypotension might be present after head trauma, especially if the client is experiencing hypovolemic or neurogenic shock, it is not a manifestation of increased intracranial pressure. Cushing's triad of hypertension, bradycardia, and a widening pulse pressure is a late manifestation of increased intracranial pressure. Although a client who has head trauma can develop fever, it is either in response to infection or due to hypothalamic damage, not due to increased intracranial pressure.

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.) A. Crepitus with joint movement B. Decreased range of motion of the affected joint C. Low-grade fever D. Spongy tissue over joints E. Joint pain that resolves with rest

A. Crepitus with joint movement. Osteoarthritis is a degenerative joint disease. Crepitus, a grating sound, is an expected finding with osteoarthritis as loosened bone and cartilage move around in the fluid inside the joint. B. Decreased range of motion of the affected joint. Decreased range of motion is an expected finding with osteoarthritis because the client's pain limits movement. E. Joint pain that resolves with rest. The client who has osteoarthritis experiences increased pain with activity and decreased pain with rest. Osteoarthritis does not cause systemic manifestations. Rheumatoid arthritis causes many systemic manifestations, including low-grade fever, weakness, anorexia, and paresthesias. Spongy joint tissue is an expected finding with rheumatoid arthritis, which is an inflammatory disease, not a degenerative disease.

A nurse in an emergency department is assessing a client who has myasthenia gravis. The client reports recent increasing muscle weakness and the nurse suspects the client is having a myasthenic crisis. Which of the following actions is the nurse's priority? A. Administer artificial tears B. Assist with a Tensilon test C. Administer immunosuppressants D. Assist with plasmapheresis

B. Assist with a Tensilon test. The first action the nurse should take using the nursing process is to assess the client. The Tensilon test will determine whether the client is having a myasthenic crisis or a cholinergic crisis. The nurse should administer artificial tears because the client might have dry eyes due to an inability to close her eyes completely. However, there is another action the nurse should take first. The nurse should administer immunosuppressants, such as corticosteroids, methotrexate, or rituximab, to reduce the manifestations of myasthenia gravis. However, there is another action the nurse should take first. Assist with plasmapheresis. The nurse should assist with plasmapheresis, which removes antibodies from the plasma and reduces the manifestations of a myasthenic crisis. However, there is another action the nurse should take first.

A nurse is caring 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? A. Remind the client that the surgery removed the limb B. Change the dressing on the client's residual limb C. Administer a dose of gabapentin to the client D. Elevate the client's residual limb above heart level

C. Administer a dose of gabapentin to the client. The nurse should administer a nonopioid medication to help minimize phantom limb pain. Gabapentin is an oral antiepileptic medication that is effective for treating sharp, burning, phantom limb pain. The nurse should only elevate the client's residual limb above the heart level within the first 48 hr following the surgery. After that time, doing so can cause a hip or knee flexion contracture. Changing the dressing on the client's residual limb does not address the client's pain. It is not therapeutic for the nurse to remind the client that the limb is gone because it does not address the client's pain.epilep

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? A. Glasgow Coma Scale score of 15 B. Intracranial pressure reading of 15 mm Hg C. Ecchymosis at base of the skull D. Clear drainage from nose

D. Clear drainage from nose. Clear drainage from the nose indicates that cerebrospinal fluid is leaking from the skull fracture. This places the client at risk for meningeal infection because micro-organisms have access to the cranium through the nose and the tear in the dura. The nurse should report this finding to the provider. Ecchymosis at base of skull A client who has a basilar skull fracture is likely to have ecchymosis at the base of the skull from a contusion. ntracranial pressure reading of 15 mm Hg An intracranial pressure reading of 15 mm Hg is at the upper limit of the expected reference range. Glasgow Coma Scale score of 15 A Glasgow Coma Scale score of 15 indicates intact neurologic functioning.

A nurse is performing a pain assessment for a client who is postoperative. Which of the following findings should the nurse use to determine the severity of the client's pain? A. Client's vital sign changes B. Client's report of the type of pain C. Client's nonverbal communication D. Client's report of pain on a pain scale

D. Client's report of pain on a pain scale. The nurse should use a client's report of pain on a standardized pain scale to determine the severity of the client's pain. Facial grimacing can identify that pain is present, but it does not identify the severity of the pain. A report of the type of pain identifies the character of the pain, such as sharp or dull, but it does not indicate the severity of the pain. A change in vital signs can identify that pain is present, but it does not identify the severity of the pain.

A nurse is teaching an assistive personnel (AP) about care of a client following a total hip arthroplasty. Which of the following instructions should the nurse include? A. Avoid applying anti-embolism stockings to the affected leg B. Have the client lean forward when moving from a sitting to a standing position C. Discourage the client from sitting in a wheelchair with the back reclined D. Place an abductor pillow between the client's legs when turning the client

D. Place an abductor pillow between the client's legs when turning the client. The nurse should inform the AP that a client who had a total hip arthroplasty should maintain the hip in abduction following surgery to reduce the risk of dislocating the surgical hip. The AP should place an abductor pillow between the client's legs when turning the client to keep her hips in abduction. The nurse should instruct the AP that a client who had a total hip arthroplasty can sit in either an upright wheelchair or one with a back that reclines to prevent hip flexion greater than 90°.

A nurse is planning to teach 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? A. Rinse with antiseptic mouthwash in place of using dental floss B. Use and over-the-counter antihistamine if a rash develops C. Slowly taper the medication after 6 consecutive months without seizure activity D. Take medications at a consistent time each day to maintain therapeutic blood levels

D. Take medications at a consistent time each day to maintain therapeutic blood levels. The client should take antiepileptic medications on a regular schedule to maintain therapeutic blood levels and achieve the maximum effect. The client should continue taking antiepileptic medications even in the absence of seizures. Stopping the medication can lead to the return of seizures or the complication of status epilepticus. The client should continue taking antiepileptic medications even in the absence of seizures. Stopping the medication can lead to the return of seizures or the complication of status epilepticus. Phenytoin can cause gingival hyperplasia, an overgrowth of gum tissue. To minimize gum injury and discomfort, the client should brush and floss after each meal, massage her gums, and schedule dental examinations regularly.

A nurse is caring for a client who has a full arm cast and reports a pain severity of 8 on a scale from 0 to 10 that pain medication does not relieve. Which of the following actions should the nurse plan to take first? A. Administer additional pain medication B. Check the circulation of the affected extremity C. Document the findings D. Reposition the affected extremity

B. Check the circulation of the affected extremity. Glasgow Coma Scale score of 15 A Glasgow Coma Scale score of 15 indicates intact neurologic functioning. Administer additional pain medication. The nurse might need to administer additional pain medication to control the client's pain. However, there is another action the nurse should take first. Document the findings. The nurse should document the findings to maintain professional standards. However, there is another action the nurse should take first. Reposition the affected extremity. The nurse might need to reposition the client's arm to promote venous return and comfort. However, there is another action the nurse should take first.

A nurse is caring for a client who is in balanced suspension skeletal traction and reports intermittent muscle spasms. Which of the following actions should the nurse take first? A. Reposition the client B. Check the position of the weights and ropes C. Administer a muscle relaxant D. Provide distraction

B. Check the position of the weights and ropes. The first action the nurse should take when using the nursing process is to assess the client. The nurse should first check the position of the weights and ropes to investigate the cause of the muscle spasms. The weights might be too heavy, or the nurse might need to realign the client. Reposition the client. The nurse should reposition the client to realign him and try to relieve his muscle spasms. However, there is another action the nurse should take first. Administer a muscle relaxant. The nurse should administer a muscle relaxant to minimize the client's muscle spasms. However, there is another action the nurse should take first. Provide distraction. The nurse should provide sensory stimulation to help the client keep his focus away from the pain of the spasms. However, there is another action the nurse should take first.

A nurse is teaching a client who has Parkinson's disease about taking carbidopa-levodopa. Which of the following statements should the nurse identify as an indication that the client understands the teaching? A. "I should expect a slight increase in my blood pressure while taking this medication." B. "I should take my medication with a high-protein food." C. "I should expect my urine to be a darker color." D. "I should expect it to take up to a week for this medication to work."

C. "I should expect my urine to be a darker color."Saliva, urine, and sweat can darken in color during carbidopa-levodopa therapy. This is a harmless adverse effect. Orthostatic hypotension is an adverse effect of carbidopa-levodopa. High-protein foods can reduce the absorption of carbidopa-levodopa and the transportation of the medication to the brain. The nurse should inform the client that it can take several months for this medication to take effect.

A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which of the following interventions is the nurse's 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. The greatest risk to the client is respiratory compromise due to progressive paralysis of respiratory muscles. Therefore, the priority intervention is to monitor the client's oxygen saturation to identify respiratory compromise as soon as possible. The nurse should provide for frequent rest periods throughout the day because the client's fatigue will increase as the disease progresses. However, this is not the priority intervention. The nurse should administer pain medication on a regular schedule to keep the client's pain level under control. However, this is not the priority intervention. Administer baclofen for spasticity. The nurse should give baclofen to manage spasticity that can interfere with self-care. However, this is not the priority intervention. f

A nurse is assessing a client who is quadriplegic following 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? A. Administer hydralazine via IV bolus B. Loosen the client's clothing C. Empty the client's bladder D. Elevate the head of the client's bed

D. Elevate the head of the client's bed. These assessment findings indicate that the client is experiencing autonomic dysreflexia and is at greatest risk for possible rupture of a cerebral vessel or increased intracranial pressure. The first action the nurse should take is to move the client from a supine to an upright position, which will result in rapid postural hypotension. The nurse should empty the client's bladder because a full bladder or a fecal impaction is a trigger of autonomic dysreflexia. However, there is another action the nurse should take first. The nurse should loosen the client's clothing because body temperature and tactile stimulation are triggers of autonomic dysreflexia. However, there is another action the nurse should take first. The nurse should administer hydralazine, a potent vasodilator, to lower the client's blood pressure. However, there is another action the nurse should take first.

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? A. Encourage the client to use the Valsalva maneuver. B. Stroke the client's inner thigh. C. Perform the Credé manuever. D. Administer a diuretic.

B. Stroke the client's inner thigh.The nurse should stimulate micturition by stroking the client's inner thigh. Other techniques include pinching the skin above the groin and providing digital anal stimulation. Encourage the client to use the Valsalva maneuver. The nurse should encourage the client to hold his breath and bear down, also known as the Valsalva maneuver, to express urine from a flaccid bladder. It is not effective with a spastic bladder due to the spasticity of the external sphincter. Perform the Credé maneuver. The nurse should apply direct pressure over the client's bladder, also known as the Credé maneuver, to express urine from a flaccid bladder. It is not effective with a spastic bladder due to the spasticity of the external sphincter. Administer a diuretic. Antispasmodics such as oxybutynin, rather than diuretics, can be effective for treating mild spastic bladder problems.

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? A. Maintain a PaCO2 of approximately 35 mm Hg B. Provide small doses of fentanyl via IV bolus for pain management C. Measure body temperature every 1 to 2 hr D. Reposition the client every 2 hr

A. Maintain a PaCO2 of approximately 35 mm Hg. The greatest risk to this client is injury from increased intracranial pressure. Therefore, the nurse's priority action is to maintain the PaCO2 at 35 to 38 mm Hg to prevent hypercarbia and subsequent vasodilation that can lead to an increase in intracranial pressure. The nurse should administer opiate pain medications to reduce agitation and restlessness during mechanical ventilation and to manage pain. Fentanyl does not affect vital signs as much as morphine does, so it is a safer choice for this client. However, this is not the nurse's priority. The nurse should monitor the client's body temperature because clients who have head injuries commonly develop a fever due to the body's response to the trauma or hypothalamic damage. However, this is not the nurse's priority. Reposition the client every 2 hr. The nurse should reposition the client at least every 2 hr to help prevent skin breakdown. However, this is not the nurse's priority.

A nurse is caring for a client who is recovering from a stroke and has right-sided homonymous hemianopsia. To help the client adapt to the hemianopsia, the nurse should take which of the following actions? A. Check the client's cheek on his affected side after he eats 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.Clients who have right-sided homonymous hemianopsia have lost the right visual field of both eyes and might only eat the food he is able to see on the left half of the meal tray. Therefore, the nurse should remind the client to look at both sides of his meal tray to help him compensate for the visual loss. Provide the client with eating utensils that have large handles. Homonymous hemianopsia does not impair the client's fine motor skills. However, as stroke can impair fine motor skills, eating utensils that have a wide grip surface can help compensate for a weak hand grasp. Encourage the client to sit upright with his head tilted slightly forward during meals. Homonymous hemianopsia does not cause dysphagia. However, as stroke can cause dysphagia, positioning the client upright and having him tilt his head forward to swallow can help prevent aspiration. Check the client's cheek on his affected side after he eats to be sure no food remains there. Homonymous hemianopsia does not cause the client to pocket food. However, food can accumulate on the affected side of the mouth, so the nurse should place food on the unaffected side of the client's mouth when feeding him.