Functional Ability

A client has a diagnosis of myasthenia gravis. The nurse recalls that associated clinical manifestations include:

Blurred vision along with episodes of vertigo

A client with diabetes is being taught to self-administer a subcutaneous injection of insulin. Identify the preferred site for the self-administration of this drug.

Abdomen

The nurse is caring for a client with Parkinson disease. Which of the following is a priority nursing concern?

Risk for injury

The nurse is providing hospital discharge teaching to a 30-year-old client who was hospitalized for exacerbation of rheumatoid arthritis. Which statement by the client indicates correct understanding of the treatment plan?

When I exercise, I will reduce the number of repetitions when I have pain."

A client admitted to the hospital with an acute episode of rheumatoid arthritis (RA) asks why physical therapy has not been prescribed. What is the most appropriate nursing response?

Your joints are still inflamed and physical therapy can be harmful."

During the first month in a nursing home, a client demonstrates numerous disorganized behaviors related to disorientation and cognitive impairment. The nurse's plan of care should continue to take into consideration the client's:

Ability to perform tasks without becoming frustrated

A nurse is teaching a client with hemiparesis how to ambulate with a cane. The nurse should instruct the client to:

Advance the cane simultaneously with the affected extremity

Building confidence in one's worth is important for a client who is scheduled for a below-the-knee amputation (BKA) because an amputation:

Affects an idealized self-image

A nurse is assigned to care for a group of clients who have been found to have depression. Which clinical manifestations does the nurse anticipate? Select all that apply.

Neglect of personal hygiene apathetic response "I don't know" responses

A client with myasthenia gravis improves and is discharged from the hospital. Discharge medications include pyridostigmine (Mestinon) 10 mg orally every six hours. The nurse evaluates that the drug regimen is understood when the client says, "I should:

Set my alarm clock to take my medication."

A client is admitted to the hospital with a diagnosis of a fractured hip after a fall. What clinical finding does the nurse expect to identify when assessing the client?

Shortening of the affected extremity

A client newly diagnosed with myasthenia gravis is concerned about fluctuations in physical condition and generalized weakness. When caring for this client it is most important for the nurse to plan to:

Space activities throughout the day

A client has a thyroidectomy for cancer of the thyroid. To evaluate for nerve injury that may be the result of surgery-related trauma, the nurse assesses the client's ability to:

Speak

After three months of rehabilitation after a craniotomy, a client continues to have motor speech difficulties. To promote the client's use of speech the nurse should

Support the client's efforts to communicate

A nurse is caring for a client with rheumatoid arthritis. Based on the client's diagnosis, the nurse should review the result of which laboratory test?

Antinuclear antibody (ANA)

A client who has degenerative joint disease of the vertebral column is taught to turn from the back to the side, while keeping the spine straight. In addition to crossing an arm over the chest, what should the nurse instruct the client to do?

Bend your top knee to the side to which you are turning.

A nurse is intervening with a client who is having a crisis. What is the nurse's concern after the initial crisis issues have been addressed?

Client's potential to perform activities of daily living

A client with rheumatoid arthritis calls the outpatient clinic to report that pain with exercising has increased. To decrease pain, the nurse should suggest:

Decrease the number of repetitions of the exercises

A young woman who is experiencing stress at a new job turns to food for comfort and induces vomiting to keep from gaining weight. When the binge-purge behaviors begin to interfere with the client's ability to meet her job responsibilities, the young woman visits the local mental health clinic. The priority nursing assessment during the initial appointment is the client's level of:

Depression

A nurse is caring for two clients. One has Parkinson disease and the other has myasthenia gravis. For what common complication associated with both disorders should the nurse assess these clients?

Difficulty swallowing

What should the nurse do to prevent deformities of the knee in a client with an exacerbation of arthritis? Select all that apply .

Encourage motion of the joint Maintain joints in functional alignment when resting.

A health care provider prescribes selegiline (Eldepryl) 5 mg twice a day for a client with a diagnosis of Parkinson disease. What is most important for the nurse to teach the client?

Ensure that an opioid is not taken currently

A client is admitted and diagnosed with myasthenia gravis. Pyridostigmine bromide (Mestinon) therapy via tablets has been prescribed. The nurse anticipates that the dosage will be changed frequently during the first week of therapy. While the dosage is being adjusted, the nurse should

Evaluate the client's muscle strength every hour after the medication is given

After a painful exacerbation of rheumatoid arthritis, a client is scheduled to begin a walking and exercise program. What is an expected outcome for this client?

Exercise and be active unless the discomfort becomes too great.

A nurse is performing range-of-motion exercises with a client who had a brain attack (cerebrovascular accident, CVA). The nurse places the client's hand in the position exhibited in the picture. This position is known as:

Extension

The nurse in the pediatric clinic is reviewing the health history of a 10-year-old girl with a diagnosis of juvenile idiopathic arthritis (JIA). Currently the child is experiencing recurrent pain and swelling of the joints, particularly her knees and ankles. What organ is commonly affected in children with this disorder?

Eyes

To what does the nurse attribute the increased risk of respiratory complications in clients with myasthenia gravis?

Ineffective coughing

A client with asthma is being taught how to use a peak flow meter to monitor how well the asthma is being controlled. What should the nurse instruct the client to do?

Inhale completely and then blow out as hard and as fast as possible through the mouthpiece

A client with a herniated nucleus pulposus is scheduled for a diskectomy with fusion. As part of the postoperative teaching plan, the nurse will discuss what type of positioning technique?

Log-rolling

A client with hemiparesis is reluctant to use a cane. The nurse explains to the client that the cane is needed to:

Maintain balance to improve stability.

The nurse is caring for a client two days after the client had a brain attack (cerebrovascular accident, CVA). To prevent the development of plantar flexion, the nurse should:

Maintain the feet at right angles to the legs

A client has been diagnosed as brain dead. The nurse understands that this means that the client has:

No cortical functioning with some reflex breathing

A client is admitted to the hospital with a recurrence of chronic arterial insufficiency of the legs. Which clinical manifestations does the nurse expect to identify when performing an admission history and physical?

Pain when exercising and thickening of the toenails

A client is admitted to the hospital with a diagnosis of emphysema. What should the nurse include when teaching the client breathing exercises?

Perform diaphragmatic exercises to improve contraction of the diaphragm

A 90-year-old female resident of a nursing home falls and fractures the proximal end of her right femur. The surgeon plans to reduce the fracture with an internal fixation device. The general fact about the older adult that the nurse should consider when caring for this client is that:

Physiological coping defenses are reduced

A client who is employed as a carpenter has trouble holding tools because of carpal tunnel syndrome but continues to work to meet family financial obligations. Which is the priority concern when health care instructions are discussed with the client?

Potential for injury

Selegiline (Eldepryl) is prescribed for a client with Parkinson disease who is having an inadequate response to dopar (Levodopa) therapy. When teaching the client about the addition of this drug to the regimen, the nurse should explain that the:

Primary health care provider should be contacted immediately if a severe headache occurs.

An older female client is concerned about maintaining her independent living status. What initial intervention strategy is of primary importance?

Reinforcing routines and supporting her usual habits

A nurse provides education to a client with myasthenia gravis about how to prevent myasthenic crisis. The nurse evaluates that the teaching is effective when the client says:

The health care provider may need to adjust the dosage of my medication if I'm more active."

A debilitated older client with glaucoma who places great value on independence is being prepared for discharge from the hospital. To promote independence, the nurse should encourage the client to:

Self-administer the eye medications using appropriate technique

A client with a long history of asthma is scheduled for surgery. What information should be included in preoperative teaching?

There is an increased risk of respiratory tract infections.

Optimal teaching for the client with multiple sclerosis (MS) who is experiencing urinary retention includes: select all that apply

Using Crede's maneuver, and Monitoring for and reporting signs of urinary tract infection.

When planning care to prevent deformities and contractures in a client with burns, the nurse expects to begin range-of-motion (ROM) exercises when the client's:

Vital signs are stable

Immediately after a subtotal thyroidectomy the nurse plans to assess a client for unilateral injury of the laryngeal nerve every 30 to 60 minutes by:

Asking the client to say what the current time is

When caring for a person with myasthenia gravis, a nurse considers the differences between myasthenic and cholinergic crises. The nurse concludes that:

Atropine is used to treat cholinergic crisis

Shortly after birth a newborn is found to have Erb's palsy. What condition does the nurse suspect caused this problem?

Injury to brachial plexus during birth

During a routine clinic visit of a client who has myasthenia gravis, the nurse reinforces previous teaching about the disease and self-care. The nurse evaluates that the teaching is effective when the client states that it is important to:

Avoid people with respiratory infections