421 Chapter 64
While assessing a newly admitted client, the nurse identifies impaired coordination, decreased muscle strength, limited range of motion, and reluctance to move. What nursing diagnosis do these signs and symptoms most clearly suggest?
Impaired physical mobility
After sustaining a stroke, a client is transferred to the rehabilitation unit. The medical-surgical nurse reviews the client's residual neurological deficits with the rehabilitation nurse. Which neurological deficit places the client at risk for skin breakdown?
Incontinence and right-sided hemiparesis
The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?
Increased pulse rate, adventitious breath sounds
A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate?
Initiate seizure precautions.
Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?
Speeds nerve impulse transmission
A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?
Stage II pressure ulcer
During assessment, a patient reports that she sometimes "wets herself" when sneezing. The nurse documents this as which of the following?
Stress incontinence
A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient?
Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.
A patient learning to ambulate with crutches advances both crutches and then lifts both feet, moving them forward and landing them in front of the crutches. The patient then repeats this motion. The nurse identifies this as which type of crutch gait?
Swing-through
The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The care plan for this client reflects the client's problem eating due to jaw pain. To assist the client in meeting the adequate nutritional needs, what should the nurse suggest?
Take small meals of soft consistency
The nurse is caring for a 35-year-old man whose severe workplace injuries necessitate bilateral below-the-knee amputations. How should the nurse anticipate that the client will respond to this news?
The client will experience grief in an individualized manner.
An adult client's current goals of rehabilitation focus primarily on self-care. What is a priority when teaching a client who has self-care deficits in ADLs?
To provide an optimal learning environment with minimal distractions
A client is diagnosed with meningococcal meningitis. The 22-year-old client shares an apartment with one other person. What would the nurse expect as appropriate care for the client's roommate?
Treatment with antimicrobial prophylaxis as soon as possible
A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. He reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder?
Trigeminal neuralgia
When developing a plan of care for a patient with impaired physical mobility who must remain on complete bedrest, which of the following would the nurse most likely include to prevent external rotation of the hip?
Trochanter roll
A client is hospitalized with Guillain-Barré syndrome. Which nursing assessment finding is most significant?
Uneven, labored respirations
A nurse is reviewing the medical record of an immobilized patient who has developed a pressure ulcer. Which nutritional deficiency would the nurse identify as placing the patient at risk for delayed wound healing?
Vitamin C
The client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. The nurse monitors blood chemistry test results and urinary output for
renal complications related to acyclovir therapy.
A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to:
rest in an air-conditioned room.
When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction?
"Avoid hot baths and showers."
The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome. An important question to ask related to the diagnosis is which of the following?
"Have you experienced any viral infections in the last month?"
A patient with a fractured left fibula is being taught how to use crutches. Which statement by the patient indicates that the teaching was effective?
"I need to allow my arms and hands to support my body weight."
While performing range-of-motion exercises for a patient, the nurse abducts the patient's shoulder. Which of the following images best depicts the nurse's action?
Nurse raising pt. arm above their head
The nurse has been educating a client newly diagnosed with MS. Which statement by the client indicates an understanding of the education?
"I will stretch daily as directed by the physical therapist."
A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates effective teaching?
"I'll eat plenty of fruits and vegetables."
A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?
"The paralysis caused by this disease is temporary."
The parents of a client intubated due to the progression of Guillain-Barré syndrome ask whether their child will die. What is the best response by the nurse?
"There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive."
A family will be providing care at home to an immobilized patient at risk for impaired skin integrity. What statement made by the family indicates that more teaching is needed?
"We elevate the head of the bed to comfort level throughout the day."
A nurse is reviewing a patient's laboratory test results. Which serum albumin level would lead the nurse to suspect that the patient is at risk for pressure ulcers?
2.5 g/mL
A client has been hospitalized for diagnostic testing. The client has just been diagnosed with multiple sclerosis, which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client?
A disorder in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self"
A nurse is working with a patient to establish a bowel training program. Based on the nurse's understanding of bowel function, the nurse would suggest planning for bowel evacuation at which time?
After breakfast
A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is most appropriate?
Alternatively patch one eye every 2 hours.
A nurse is assessing a client for potential problems related to function and mobility. Which of the following would alert the nurse to identify a potential problem related to function or movement?
Holds onto the furniture when walking in the house
A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis?
Neck flexion produces flexion of the knees and hips
A nurse is assisting a client with range-of-motion exercises. The nurse moves the client's leg out and away from the midline of the body. What movement does the nurse document?
Abduction
Which of the following is the medication of choice in the treatment of herpes simplex virus (HSV)?
Acyclovir (Zovirax)
An elderly woman diagnosed with osteoarthritis has been referred for care. The client has difficulty ambulating because of chronic pain. When creating a nursing care plan, what intervention will best promote the client's mobility?
Administer an analgesic as prescribed to facilitate the client's mobility.
During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do?
Administer atropine to control the side effects of edrophonium.
The nurse is administering the IV antiviral medication ganciclovir (Cytovene) to the patient with HSV-1 encephalitis. What is the best way for the nurse to administer the medication to avoid crystallization of the medication in the urine?
Administer via slow IV over 1 hour.
A female client has been achieving significant improvements in her ADLs since beginning rehabilitation after a brain hemorrhage. The nurse must observe and assess the client's ability to perform ADLs to determine the client's level of independence in self-care and her need for nursing intervention. Which of the following additional considerations should the nurse prioritize?
Appraising the family's involvement in the client's ADLs.
The nurse is admitting a client into the rehabilitation unit after an industrial accident. The client's nursing diagnoses include disturbed sensory perception and the nurse identifies that he has decreased strength and dexterity. The nurse should know that this client may need what to accomplish self-care?
Appropriate assistive devices
Which nursing intervention is the priority for a client in myasthenic crisis?
Assessing respiratory effort
Which drug should be available to counteract the effect of edrophonium chloride?
Atropine
For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs?
Attaching braces or splints to each foot and leg
A nurse is providing education to a client with newly diagnosed multiple sclerosis (MS). Which of the following will the nurse include?
Avoid hot temperatures.
The nurse is caring for a client admitted with a diagnosis of septic meningitis. The nurse is aware that this infection is caused by which of the following?
Bacteria
Students are reviewing information about activities of daily living. They demonstrate understanding of this topic when they identify which of the following as an activity of daily living?
Bathing
A nurse is completing an assessment of a client who has just been transferred to the rehabilitation facility. During the health history, the nurse asks about the client's activities of daily living (ADLs). About which areas would the nurse gather information? Select all that apply.
Bathing Toileting Eating
The nurse is caring for a client with a stiff and painful neck and sensitivity to light. Which diagnostic test will the nurse expect to be prescribed for this client? Select all that apply.
Computed tomography scan Blood cultures
Which is the primary medical management of arthropod-borne virus (arboviral) encephalitis?
Controlling seizures and increased intracranial pressure
Cerebrospinal fluid (CSF) studies would indicate which of the following in a patient suspected of having meningitis? Select all that apply.
Decreased glucose Increased protein Increased white blood cells
A nurse is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan?
Develop a written, individual turning schedule.
A nurse assesses an older adult's risk for pressure ulcers based on the understanding that which of the following increases the client's susceptibility?
Diminished dermal collagen
The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe?
Diplopia and ptosis
A nurse is caring for a client who is documented to have orthostatic hypotension. The nurse anticipates finding which symptom upon assessment?
Dizziness
Which is an indicator of orthostatic hypotension?
Dizziness
A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease?
Edrophonium (Tensilon)
A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function improves after the client receives an IV injection of a medication. What is the medication the nurse tells the client he'll receive during this test?
Edrophonium (Tensilon)
A rehabilitation nurse is assisting a patient to cope with a disability. Which of the following would the nurse suggest?
Emphasize areas of strengths.
The nurse is performing an initial assessment on a client with suspected Bell's palsy. Which of the following findings would the nurse be most focused on related to this medical diagnosis?
Facial distortion and pain
While performing an initial nursing assessment on a client admitted with suspected tic douloureux (trigeminal neuralgia), for which of the following would the nurse expect to observe?
Facial pain in the areas of the fifth cranial nerve
A nurse is developing a teaching plan for a patient with urinary incontinence who will be performing intermittent self-catheterization. Which of the following would be most important for the nurse to emphasize?
Following a regular emptying schedule
A nurse is assessing a patient's level of independent functioning. Which tool would the nurse most frequently use?
Functional Independence Measure
The nurse is assessing a client with meningitis. Which of the following signs would the nurse expect to observe?
Headache and nuchal rigidity
You are the nurse caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the complications of the disorder, what should you keep always ready at the bedside?
Intubation tray and suction apparatus
A client spends most of his time in a wheelchair. The nurse would be especially alert for the development of pressure ulcers in which area?
Ischial tuberosity
An older adult experienced a cerebrovascular disease 6 weeks ago and is currently receiving inpatient rehabilitation. The nurse is coaching the client to contract and relax her muscles while keeping her extremity in a fixed position. Which type of exercise is the client performing?
Isometric
Which nursing intervention can help a client maintain healthy skin?
Keeping the client well hydrated
The nurse is caring for a patient admitted to the hospital with a brain abscess that developed from an untreated case of otitis media. What assessment data is a priority to alert the nurse to changes in intracranial pressure?
Level of consciousness
The diagnosis of multiple sclerosis is based on which test?
Magnetic resonance imaging (MRI)
The nurse is planning care for a client with Guillain-Barre syndrome. The priority client outcome would be which of the following?
Maintains effective respirations and airway clearance
Which is the primary vector of arthropod-borne viral encephalitis in North America?
Mosquitoes
A patient in rehabilitation has become dependent on family members' assistance with self-care. What can the nurse do to encourage the patient to become independent? (Select all that apply.)
Motivate the patient to learn and accept responsibilities for self-care. Help the patient identify safe limits of independent activity. Educate the patient in how to perform self-care activities.
Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord?
Multiple sclerosis
A client is receiving baclofen for management of symptoms associated with multiple sclerosis. To evaluate the effectiveness of this medication, what does the nurse assess?
Muscle spasms
The nurse is performing an initial nursing assessment on a client with possible Guillain-Barre syndrome. Which of the following findings would be most consistent with this diagnosis?
Muscle weakness and hyporeflexia of the lower extremities
A nurse is performing passive range of motion to a client's upper extremities. The nurse touches the client's thumb to each fingertip on the same hand. The nurse is performing which of the following?
Opposition
The most common cause of cholinergic crisis includes which of the following?
Overmedication
When describing the role of the various members of the rehabilitation team, which member would the nurse identify as the one who determines the final outcome of the process?
Patient
The nurse is performing range-of-motion exercises. Which of the following best depicts dorsiflexion of the foot?
Pic with nurse's hand cupping pt's heel and pt foot resting against nurse's forearm
After teaching a patient about the proper method for using crutches to assist in ambulation, the nurse observes the patient's crutch-gait. The nurse determines that the patient has understood the instructions when the patient demonstrates which of the following images as the beginning stance? Note that the shaded areas are weight-bearing and the arrows indicate advancement of the foot or crutch.
Picture with both feet yellow and two yellow dots right above them
A rehabilitation nurse is preparing a presentation for clients and caregivers about issues that clients with disabilities may face. Which of the following would be most appropriate for the nurse to include in the presentation?
Priority setting is helpful in dealing with the impact of the disability.
A nurse is preparing an in-service presentation that focuses on promoting pressure ulcer healing. The nurse is planning to include information about appropriate nutrition. Which of the following would the nurse include as important for overall tissue repair?
Protein
Which is a component of the nursing management of the client with variant Creutzfeldt-Jakob disease (vCJD)?
Providing palliative care
A patient has a nursing diagnosis of risk for impaired skin integrity related to immobility and secondary to diabetes. As part of the plan of care, the nurse plans to reposition the patient frequently. Based on an understanding of positioning and its effects, the nurse identifies which position as preferred to the semi-Fowler's position?
Recumbent
A patient diagnosed with MS 2 years ago has been admitted to the hospital with another relapse. The previous relapse was followed by a complete recovery with the exception of occasional vertigo. What type of MS does the nurse recognize this patient most likely has?
Relapsing-remitting (RR)
A client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. To ensure early intervention, the nurse monitors laboratory values and urine output for which type of adverse reactions?
Renal
A nurse is caring for a client who requires a wheelchair. Which piece of equipment impedes circulation to the area it's meant to protect?
Ring or donut
A frontal lobe brain abscess produces which manifestation?
Seizures
The nurse is assessing a patient at risk for the development of a pressure ulcer. What laboratory test will assist the nurse in determining this risk?
Serum albumin
The nurse is developing a bowel training program for a patient. What education can the nurse provide for the patient that will increase the chance of success of the bowel program? (Select all that apply.)
Set a daily defecation time that is within 15 minutes of the same time every day. Have an adequate intake of fiber containing foods. Have a fluid intake between 2 and 4 L/day.
A client is preparing for discharge from the emergency department after sustaining an ankle sprain. The client is instructed to avoid weight bearing on the affected leg and is given crutches. After instruction, the client demonstrates proper crutch use in the hallway. What additional information is most important to know before discharging the client?
Whether the client needs to navigate stairs routinely at home
When is the optimal time for the nurse to begin the rehabilitation process for a patient with a cervical spine injury?
With initial patient contact
A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient?
Within 24 hours after exposure
A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then:
advance both crutches.
A neurologic deficit is best defined as a deficit of the:
central and peripheral nervous systems with decreased, impaired, or absent functioning.
A client who recently had a stroke requires a cane to ambulate. When teaching about cane use, how should the nurse explain that the reason for holding a cane on the uninvolved side?
distribute weight away from the involved side.
The primary arthropod vector in North America that transmits encephalitis is the
mosquito.
A nurse is performing a baseline assessment of a client's skin integrity. What are the priority assessments? Select all that apply.
presence of pressure ulcers on the client overall risk of developing pressure ulcers potential areas of pressure ulcer development
A female client reports to a nurse that she experiences a loss of urine when she jogs. The nurse's assessment reveals no nocturia, burning, discomfort when voiding, or urine leakage before reaching the bathroom. The nurse explains to the client that this type of problem is called:
stress incontinence.
