hiok

nurse is assisting in the care of a client who is being evaluated for possible myasthenia gravis. The primary health care provider gives a test dose of edrophonium. The nurse recalls that the client should have which reaction if the client has this disease?

increase in muscle strength within 1-3 minutes

client receives a dose of edrophonium. The client shows improvement in muscle strength for a period of time following the injection. The nurse should interpret this finding as indicative of which disease process?

myasthenia gravis

When the nurse taps at the level of the client's facial nerve, the following response is noted. How should the nurse document this finding on the client's record? Refer to figure.

positive chvostek sign

client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse expects the cervical collar will remain in place until which time?

primary health care provider (PHCP) reviews the x-ray results.

The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client?

explaining equipment and procedure on an ongoing basis

The nurse is assisting in gathering data on cranial nerve XII of a client who sustained a brain attack (stroke). The nurse understands that the client should be asked to perform which action?

extend the tongue

43 of 100 An adult client had a cerebrospinal fluid (CSF) analysis after lumbar puncture. The nurse interprets which finding as abnormal if present? 1. Protein 2. Glucose 3. Red blood cells 4. White blood cells

Correct Answer: 3

57 of 100 The nurse is caring for a client with a spinal cord injury. High-top sneakers on the client's feet will prevent the occurrence of which? 1. Foot drop 2. Plantar flexion 3. Pressure ulcers 4. Deep vein thrombosis

Correct Answer: 1

A client with a neurological impairment experiences urinary incontinence. Which nursing action should help the client adapt to this alteration?

Establishing a toileting schedule

The nurse observes that a client with Parkinson's disease has very little facial expression. The nurse attributes this piece of data to which information?

Masklike facies is a component of Parkinson's disease.

The nurse is assisting with caring for a client after a craniotomy. Which are the positions that can be used for the client? Select all that apply. Prone position 2. Supine position 3. 4. Dorsal recumbent position 5. 6. With the foot of the bed elevated 30 degrees

With the foot of the bed flat Semi-Fowler's position

48 of 100 The nurse is assisting in caring for a client with a suspected diagnosis of meningitis. The nurse reinforces to the client information regarding which diagnostic test that is commonly used to confirm this diagnosis? 1. Urine culture 2. Lumbar puncture 3. Serum electrolytes 4. White blood cell (WBC) count

Correct Answer: 2

88 of 100 Which information will the nurse reinforce to the client scheduled for a lumbar puncture? 1. An informed consent will be required. 2. The test will probably take about 2 hours. 3. Food and fluids will be restricted until after the test is completed. 4. There is no need to maintain a supine position following the test.

Correct Answer: 1

63 of 100 The nurse is monitoring a client with a head injury and notes that the client is assuming the posture shown in the figure. What is the client exhibiting that would require the nurse to notify the registered nurse immediately? Refer to the figure. 1. Opisthotonos 2. Flaccid quadriplegia 3. Decorticate posturing 4. Decerebrate posturing

Correct Answer: 3

HomeHelpCalculator Review Mode Question 42 of 100 ID: 2164 | file: Adult Health_Neuro PreviousGoNext StopBookmark Rationale Strategy Reference Submit The nurse is caring for a client with a diagnosis of multiple sclerosis (MS) who has been prescribed amantadine. The client asks the nurse why the amantadine has been prescribed. Which response should the nurse make? 1. "It is prescribed to relieve fatigue." 2. "It is prescribed to decrease spasticity." 3. "It is prescribed to treat urinary retention." 4. "It is prescribed to relieve neuropathic pain."

Correct Answer: 1

64 of 100 The nurse is collecting data on a client suspected of having Alzheimer's disease. The priority data should focus on which characteristics of this disease? Select all that apply. 1. Difficulty learning 2. Recent memory loss 3. Problems with concrete thinking 4. Difficulty in performing new tasks 5. Problems with hearing and discriminating the spoken word from other sounds

Correct Answer: 1, 2

40 of 100 The nurse is monitoring a client with a C5 spinal cord injury for spinal shock. Which findings would be associated with spinal shock in this client? Select all that apply. 1. Bowel sounds are absent. 2. The client's abdomen is distended. 3. Respiratory excursion is diminished. 4. The blood pressure rises when the client sits up. 5. Accessory muscles of respiration are areflexic.

Correct Answer: 1, 2, 3, 5

The nurse is caring for a client with an intracranial aneurysm who was previously alert. Which findings are early indications that the level of consciousness (LOC) is deteriorating? Select all that apply. 1. Drowsiness 2. Clear speech 3. Less frequent speech 4. Ptosis of the left eyelid 5. Slight slurring of speech 6.

Correct Answer: 1, 3, 5

41 of 100 Which symptoms would validate the diagnosis of a cluster headache? Select all that apply. 1. A runny nose 2. Photophobia 3. Phonophobia 4. Burning sensation in the eye 5. Tearing on the affected eye Incorrect ✓ ✓ ✓ Terms and Conditions | Privacy Policy | Contact Us | Copyright © 2018 Elsevier Inc. All rights reserved. Evolve® is a registered trademark of Elsevier Inc. in the United States and other jurisdictions. For problems or suggestions regarding this service, submit a ticket at http://evolvesupport.elsevier.com/

Correct Answer: 1, 4, 5

45 of 100 The nurse is preparing a plan of care to monitor for complications in a client who will be returning from the operating room following transsphenoidal resection of a pituitary adenoma. Which nursing intervention does the nurse document in the plan as a priority for this client? 1. Monitor temperature. 2. Monitor urine output. 3. Monitor blood pressure. 4. Monitor apical pulse rate. Incorrect ✓ Terms and Conditions | Privacy Policy | Contact Us | Copyright © 2018 Elsevier Inc. All rights reserved. Evolve® is a registered trademark of Elsevier Inc. in the United States and other jurisdictions. For problems or suggestions regarding this service, submit a ticket at http://evolvesupport.elsevier.com/

Correct Answer: 2

A client has a halo vest that was applied following a C6 spinal cord injury. The nurse performs which action to determine whether the client is ready to begin sitting up?

Compares the client's pulse and blood pressure when both flat and sitting

22 of 100 ID: 2632 | The nurse caring for a client following a craniotomy monitors for signs of increased intracranial pressure (ICP). Which indicates an early sign of increased ICP?

Confusion

34 of 100 The client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, which immediate action should the nurse take? 1. Raise the head of the bed and remove the noxious stimulus. 2. Lower the head of the bed and remove the noxious stimulus. 3. Lower the head of the bed and administer an antihypertensive agent. 4. Remove the noxious stimulus and administer an antihypertensive agent.

Correct Answer: 1

36 of 100 The nurse is planning care for a client in spinal shock. Which action would be least helpful in minimizing the effects of vasodilation below the level of the injury? 1. Moving the client quickly as one unit 2. Using vasopressor medications, as prescribed 3. Applying compression stockings, as prescribed 4. Monitoring vital signs before and during position changes

Correct Answer: 1

75 of 100 The nurse is reinforcing instructions to the family of a stroke client who has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to use if they state that they will do which? 1. Place objects in the client's impaired field of vision. 2. Approach the client from the impaired field of vision. 3. Discourage the client from wearing his or her own eyeglasses. 4. Remind the client to turn the head to scan the lost visual field.

Correct Answer: 4

75 of 100 The nurse is reinforcing instructions to the family of a stroke client who has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to use if they state that they will do which? 1. Place objects in the client's impaired field of vision. 2. Approach the client from the impaired field of vision. 3. Discourage the client from wearing his or her own eyeglasses. 4. Remind the client to turn the head to scan the lost visual field. Incorrect

Correct Answer: 4

76 of 100 The nurse is preparing a plan of care for a client with a brain attack (stroke) who has global aphasia. The nurse incorporates communication strategies in the plan of care, knowing that the client's speech should fit which characterization? 1. Rambling 2. Difficult to understand 3. Characterized by literal paraphasia 4. Associated with poor comprehension

Correct Answer: 4

The nurse is collecting data on a client with myasthenia gravis. The nurse determines that the client may be developing myasthenic crisis if the client makes which statement?

I can't swallow very well today

client with Parkinson's disease is experiencing a parkinsonian crisis. The nurse should immediatelyplace the client where?

In a quiet, dim room with respiratory and cardiac support available

client has experienced an episode of myasthenic crisis. The nurse collects data to determine whether the client has experienced which precipitating factor?

Omitted doses of medication

The nurse is collecting data on a client with a diagnosis of meningitis and notes that the client is assuming this posture. (Refer to figure.) The nurse contacts the registered nurse and reports that the client is exhibiting which?

Opisthotonos

The nurse is preparing for the admission of a client with a prescription for seizure precautions. Which supplies will the nurse make available to this client? Select all that apply.

Oxygen Suction machine Prescribed diazepam Padding for the side rails

23 of 100 A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? Select all that apply.

Pad the bed's side rails. Place an airway at the bedside. Place oxygen equipment at the bedside. Place suction equipment at the bedside

The nurse is ambulating a client with a known seizure disorder. The client says, "I'm seeing those flashing lights again," then loses consciousness and develops a clonic-tonic seizure. Which would be the nurse's initial action?

assist client to the floors

nurse is preparing for the admission of a client with a suspected diagnosis of herpes simplex encephalitis. Which diagnostic test should be prescribed to confirm this diagnosis?

brain biopsy

he nurse is monitoring a client with a blunt head injury sustained from a motor vehicle crash. Which would indicate a basal skull fracture as a result of the injury? Select all that apply.

bruising behind ears bruising around eyes bloody or clear drainage from the auditory canal

nurse is collecting data on a client diagnosed with Parkinson's disease. Which finding indicates a serious complication of this disorder?

congested cough and coarse ronchi heard during auscultation

89 of 100 The nurse notes documentation that a postcraniotomy client is having difficulty with body image. The nurse determines that the client is still working on the postoperative outcome criteria when the client indicates which altered personal appearance? 1. Wears a turban to cover the incision 2. Indicates that facial puffiness will be a permanent problem 3. Verbalizes that periorbital bruising will disappear over time 4. States an intention to purchase a hairpiece until the hair has grown back

correct Answer 2

59 of 100 The nurse reviews the primary health care provider's treatment plan for a client with Guillain-Barré syndrome. Which prescription noted in the client's record should the nurse question? 1. Clear liquid diet 2. Vital signs every 2 to 4 hours 3. Bilateral calf measurements three times daily 4. Passive range-of-motion exercises three times daily

Correct Answer: 1

46 of 100 The family of an unconscious client with increased intracranial pressure is talking at the client's bedside. They are discussing the gravity of the client's condition and wondering if the client will ever recover. How should the nurse interpret the client's situation? 1. It is possible the client can hear the family. 2. The family needs immediate crisis intervention. 3. The client may have wanted a visit from the hospital chaplain. 4. The family could benefit from a conference with the primary health care provider.

Correct Answer: 1

client with a T4 spinal cord injury is to be monitored for autonomic dysreflexia (hyperreflexia). Which finding is indicative of this complication?

headace

39 of 100 A client has a cerebellar lesion. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item? 1. Walker 2. Slider board 3. Raised toilet seat 4. Adaptive eating utensils

Correct Answer: 1

85 of 100 The nurse is monitoring a client with a spinal cord injury who is experiencing spinal shock. Which assessment will provide the nurse with the bestinformation about recovery from the spinal shock? 1. Reflexes 2. Pulse rate 3. Temperature 4. Blood pressure

Correct Answer: 1

95 of 100 The nurse is assisting in caring for a client who sustained a traumatic head injury following a motor vehicle crash. The nurse documents that the client is exhibiting decerebrate posturing. The nurse bases this documentation on which observation? 1. Flexion of the extremities and pronation of the arms 2. Extension of the extremities and pronation of the arms 3. Upper extremity flexion with lower extremity extension 4. Upper extremity extension with lower extremity flexion

Correct Answer: 2

100 of 100 The nurse is caring for a client who has undergone craniotomy with a supratentorial incision. The nurse should plan to place the client in which position postoperatively? 1. Head of bed flat, head and neck midline 2. Head of bed flat, head turned to the nonoperative side 3. Head of bed elevated 30 to 45 degrees, head and neck midline 4. Head of bed elevated 30 to 45 degrees, head turned to the operative side

Correct Answer: 3

79 of 100 A client has just undergone lumbar puncture (LP). The nurse assists the client into which optimal position? 1. Side-lying, with a pillow under the hip 2. Prone, in slight Trendelenburg's position 3. Flat, turning from side to side as needed 4. Supine, with the head of the bed elevated 15 degrees

Correct Answer: 3

84 of 100 ID: 3365 | file: Adult Health_Neuro PreviousGoNext StopBookmark Rationale Strategy Reference Submit The nurse is monitoring a client with a spinal cord injury for signs of spinal shock. Which sign is indicative of this complication of a spinal cord injury? 1. Hypertension 2. Tachycardia 3. Profuse diaphoresis 4. Areflexia below the level of injury

Correct Answer: 4

92 of 100 The nurse has given suggestions to the client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client made which statement? 1. "I will wash my face with cotton pads." 2. "I'll have to start chewing on the unaffected side." 3. "I should rinse my mouth if tooth brushing is painful." 4. "I will try to eat my food either very warm or very cold."

Correct Answer: 4

98 of 100 The nurse is reinforcing discharge instructions to a client who has undergone transsphenoidal surgery for a pituitary adenoma. Which statement by the client indicates understanding of the discharge instructions? 1. "I need to remove the nasal packing in 1 week." 2. "I need to cough and deep breathe every 2 hours." 3. "I can take acetaminophen (Tylenol) if I get a severe headache." 4. "I need to call the doctor if I develop frequent swallowing or postnasal drip."

Correct Answer: 4

38 of 100 A nursing student is collecting data on a client recently diagnosed with meningitis. The student expects to note which signs and symptoms? Select all that apply. 1. Diarrhea 2. Tinnitus 3. Tachycardia 4. Photophobia 5. Red, macular rash 6. Positive Kernig's sign

Correct Answer: 3, 4, 5, 6

29 of 100 A client who is paraplegic after spinal cord injury has been taught muscle-strengthening exercises for the upper body. The nurse determines that the client will derive the least muscle-strengthening benefit from which activity? 1. Squeezing rubber balls 2. Doing push-ups in a prone position 3. Extending the arms while holding weights 4. Doing active range of motion to finger joints

Correct Answer: 4

87 of 100 A client with Bell's palsy exhibits facial asymmetry and cannot close the eye completely on one side. The client is also drooling and has loss of tearing in one eye. The nurse documents that the client displays symptoms of involvement of which cranial nerve (CN)? 1. CN I 2. CN IV 3. CN V 4. CN VII Incorrect

Correct Answer: 4

74 of 100 The nurse is caring for a client who was diagnosed with Bell's palsy 1 week ago. Which data would indicate a potential complication associated with Bell's palsy? 1. Excessive tearing 2. Partial facial paralysis 3. The ability to taste food 4. Negative outcomes on the electromyography

Correct Answer: 1

74 of 100 The nurse is caring for a client who was diagnosed with Bell's palsy 1 week ago. Which data would indicate a potential complication associated with Bell's palsy? 1. Excessive tearing 2. Partial facial paralysis 3. The ability to taste food 4. Negative outcomes on the electromyography

Correct Answer: 1

78 of 100 The nurse is planning care for the client with hemiparesis of the right arm and leg. Where should the nurse plan to place objects needed by the client? 1. Within the client's reach, on the left side 2. Within the client's reach, on the right side 3. Just out of the client's reach, on the left side 4. Just out of the client's reach, on the right side

Correct Answer: 1

74 of 100 The nurse is caring for a client who was diagnosed with Bell's palsy 1 week ago. Which data would indicate a potential complication associated with Bell's palsy? 1. Excessive tearing 2. Partial facial paralysis 3. The ability to taste food 4. Negative outcomes on the electromyography

Correct Answer: 3

HomeHelpCalculator Review Mode Question 58 of 100 A client with spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. Which is the best response by the nurse? 1. Ask the family to deliver the care. 2. Leave the client alone until ready to participate. 3. Advise the client that rehabilitation progresses more quickly with cooperation. 4. Acknowledge the client's anger and continue to encourage participation in care.

Correct Answer: 4

47 of 100 The nurse has obtained a personal and family history from a client with a neurological disorder. Which finding in the client's history is least likely associated with a risk for neurological problems? 1. Allergy to pollen 2. Previous back injury 3. History of headaches 4. History of hypertension

Correct Answer: 1

83 of 100 A resident in a long-term care facility prepares to walk out into a rainstorm after saying, "My father is waiting to take me for a ride." An appropriate response by the nurse is which? 1. "I need you to sign a form before leaving." 2. "If you try to leave, I will need to restrain you." 3. "How old are you? Your father must no longer be living." 4. "I'm glad you told me that. Let's have a cup of coffee and you can tell me about your father."

Correct Answer: 4

61 of 100 A client with a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the nurse should avoid which action? 1. Giving the client thin liquids 2. Thickening liquids to the consistency of oatmeal 3. Placing food on the unaffected side of the mouth 4. Allowing plenty of time for chewing and swallowing

Correct Answer: 1

27 of 100 A client is admitted to the emergency department with a C4 spinal cord injury. The nurse performs which intervention first when collecting data on the client? 1. Taking the temperature 2. Observing for dyskinesia 3. Monitoring the respiratory rate 4. Checking extremity muscle strength

Correct Answer: 3

81 of 100 The nurse is teaching the client with myasthenia gravis about prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by which activity? 1. Eating large, well-balanced meals 2. Doing muscle-strengthening exercises 3. Doing all chores early in the day while less fatigued 4. Taking medications on time to maintain therapeutic blood levels

Correct Answer: 4

30 of 100 The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric brain attack (stroke). The nurse notes that the client is alert and oriented to time and place. Based on these findings, the nurse makes which determination? 1. The client experienced a very mild stroke. 2. The client suffered a transient ischemic attack. 3. The client may have perceptual and spatial disabilities. 4. The client may have difficulty with language abilities only.

Correct Answer: 3

37 of 100 The nurse is caring for a client following craniotomy who has a supratentorial incision. The nurse reviews the client's plan of care, expecting to note that the client should be maintained in which position? 1. Prone position 2. Supine position 3. Semi-Fowler's position 4. Dorsal recumbent position

Correct Answer: 3

76 of 100 The nurse is preparing a plan of care for a client with a brain attack (stroke) who has global aphasia. The nurse incorporates communication strategies in the plan of care, knowing that the client's speech should fit which characterization? 1. Rambling 2. Difficult to understand 3. Characterized by literal paraphasia 4. Associated with poor comprehension Incorrect

Correct Answer: 4

52 of 100 The nurse notices that a client with trigeminal neuralgia has been withdrawn, is having frequent episodes of crying, and is sleeping excessively. Which method is the best way for the nurse to explore issues with the client regarding these behaviors? 1. Have the client express the feelings in writing. 2. Have the primary health care provider speak to the client. 3. Conduct a group discussion with the client's family. 4. Ignore the behavior because it is expected in clients with trigeminal neuralgia.

Correct Answer: 1

The nurse is providing care to a client with increased intracranial pressure (ICP). Which approaches would be beneficial in controlling the client's ICP from an environmental viewpoint? Select all that apply. 1. Reducing environmental noise 2. Maintaining a calm atmosphere 3. Allowing the client uninterrupted time for sleep 4. Clustering nursing activities to be done all at once 5. Keeping overhead lights on most of the day and night

Correct Answer: 1, 2, 3

70 of 100 The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made? 1. "I will use a straw for drinking." 2. "I will drive only during the daytime." 3. "I will use caution because the device alters balance." 4. "I will wash the skin daily under the lamb's-wool liner of the vest."

Correct Answer: 2

The nurse is assisting in admitting a client who experienced seizure activity in the emergency department. The nurse avoids which action when managing this client's environment? 1. Placing padding on the side rails of the bed 2. Having intravenous (IV) equipment available 3. Keeping the bed position raised to the nurse's waist level 4. Ensuring that an airway, oxygen, and suction equipment are at the bedside

Correct Answer: 3

31 of 100 A halo vest is applied to a client following a cervical spine fracture. The nurse reinforces instructions to the client regarding safety measures related to the vest. Which statement by the client indicates a need for further teaching? 1. "I will scan the room to see things." 2. "I will wear rubber-soled shoes for walking." 3. "I will use a walker for ambulating if I need to." 4. "I will bend at the waist, keeping the halo vest straight to pick up items."

Correct Answer: 4

35 of 100 Family members of an elderly client ask the nurse if there is any test to determine if a person will eventually get Alzheimer's disease? Which appropriate response should the nurse make? 1. "A radionuclide imaging (brain scan) test can predict Alzheimer's disease." 2. "A magnetic resonance imaging (MRI) scan can tell if a person will get Alzheimer's disease." 3. "A positron emission tomography (PET) scan can be a test to determine if a person will get Alzheimer's disease." 4. "There are no tests to determine if a person will get Alzheimer's disease, but research for new diagnostic tests will continue."

Correct Answer: 4

53 of 100 A client is about to undergo a lumbar puncture (LP). The nurse tells the client that which position will be used during the procedure? 1. Side-lying with a pillow under the hip 2. Prone with a pillow under the abdomen 3. Prone in slight Trendelenburg's position 4. Side-lying with the legs pulled up and the head bent down onto the chest

Correct Answer: 4

93 of 100 The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has an ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which items into the client's room? 1. Nebulizer and pulse oximeter 2. Blood pressure cuff and flashlight 3. Flashlight and incentive spirometer 4. Electrocardiographic monitoring electrodes and intubation tray

Correct Answer: 4

32 of 100 Which signs/symptoms are observed in the clonic phase of a seizure? Select all that apply. 1. Body stiffening 2. Muscular relaxation 3. Sudden loss of consciousness 4. Brief flexion of the extremities 5. Extension spasms of the body 6. Contortion of the face with eye rolling

Correct Answer: 2, 5, 6

66 of 100 The nurse is assigned to care for an adult client who had a stroke and is aphasic. Which interventions should the nurse use for communicating with the client? Select all that apply. 1. Face the client when talking. 2. Speak slowly and maintain eye contact. 3. Use gestures when talking to enhance words. 4. Avoid the use of body language when talking to the client. 5. Give the client directions using short phrases and simple terms. 6. Phrase what was said differently the second time, if there is a need to repeat it.

Correct Answer: 1, 2, 3, 5

51 of 100 The nurse develops a plan of care for a client following a lumbar puncture. Which interventions should be included in the plan? Select all that apply. 1. Monitor the client's ability to void. 2. Maintain the client in a flat position. 3. Restrict fluid intake for a period of 2 hours. 4. Monitor the client's ability to move the extremities. 5. Inspect the puncture site for swelling, redness, and drainage. 6. Maintain the client on a nothing-by-mouth (NPO) status for 24 hours.

Correct Answer: 1, 2, 4, 5

49 of 100 The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions by the nurse would be contraindicated? Select all that apply. 1. Restrain the client's limbs. 2. Loosen restrictive clothing. 3. Consider insertion of a padded tongue blade. 4. Remove the pillow and raise the padded side rails. 5. Position the client to the side, if possible, with head flexed forward.

Correct Answer: 1, 3

70 of 100 The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made? 1. "I will use a straw for drinking." 2. "I will drive only during the daytime." 3. "I will use caution because the device alters balance." 4. "I will wash the skin daily under the lamb's-wool liner of the vest."

Correct Answer: 2

82 of 100 The nurse observes the unlicensed assistive personnel (UAP) positioning the client with increased intracranial pressure (ICP). Which position would require intervention by the nurse? 1. Head midline 2. Head turned to the side 3. Neck in neutral position 4. Head of bed elevated 30 to 45 degrees

Correct Answer: 2

82 of 100 The nurse observes the unlicensed assistive personnel (UAP) positioning the client with increased intracranial pressure (ICP). Which position would require intervention by the nurse? 1. Head midline 2. Head turned to the side 3. Neck in neutral position 4. Head of bed elevated 30 to 45 degrees

Correct Answer: 2

96 of 100 A client who suffered a cervical spine injury had Crutchfield tongs applied in the emergency department. The nurse should avoid which action in the care of the client? 1. Placing the client on a Stryker frame 2. Removing the weights when repositioning the client 3. Checking the status and integrity of the weights and pulleys 4. Checking the amount of traction in use against the prescription each shift

Correct Answer: 2

54 of 100 A client experiences an episode of Bell's palsy and complains about increasing clumsiness. The nurse should prepare the client for which diagnostic study (studies) to determine the cause of the complaints? Select all that apply. 1. Serum sodium level 2. Cerebral angiography 3. Lumbar puncture (LP) 4. Oculovestibular reflex 5. Electroencephalogram 6. Computed tomography

Correct Answer: 2, 3, 6

69 of 100 A client in the emergency department is diagnosed with Bell's palsy. The nurse collecting data on this client expects to note which observations? Select all that apply. 1. Double vision 2. Excessive tearing 3. Inability to furrow brow 4. Pain in cheek, jaw, and teeth 5. Altered level of consciousness 6. A lag in closing the bottom eyelid

Correct Answer: 2, 3, 6

91 of 100 The nurse has applied a hypothermia blanket to a client with a fever. The nurse should inspect the skin frequently to detect which complications of hypothermia blanket use? Select all that apply. 1. Frostbite 2. Skin breakdown 3. Arterial insufficiency 4. Venous insufficiency 5. Diminished peripheral perfusion

Correct Answer: 2, 5

27 of 100 A client is admitted to the emergency department with a C4 spinal cord injury. The nurse performs which intervention first when collecting data on the client? 1. Taking the temperature 2. Observing for dyskinesia 3. Monitoring the respiratory rate 4. Checking extremity muscle strength

Correct Answer: 3

44 of 100 The nurse is caring for a client with a diagnosis of multiple sclerosis who has been prescribed oxybutynin. The nurse evaluates the effectiveness of the medication by asking the client which question? 1. "Are you consistently fatigued?" 2. "Are you having muscle spasms?" 3. "Are you getting up at night to urinate?" 4. "Are you having normal bowel movements?" Incorrect ✓ Terms and Conditions | Privacy Policy | Contact Us | Copyright © 2018 Elsevier Inc. All rights reserved. Evolve® is a registered trademark of Elsevier Inc. in the United States and other jurisdictions. For problems or suggestions regarding this service, submit a ticket at http://evolvesupport.elsevier.com/

Correct Answer: 3

65 of 100 A client with Guillain-Barré syndrome has been asking many questions about the condition, and the nursing staff feels that the client is very discouraged about her condition. It is important for the nurse to include which information in discussions with the client? 1. Paralysis occurs proximally to distally. 2. Maximum paralysis occurs within 48 hours following diagnosis. 3. Generally, a vast number of people recover from this condition. 4. With maximum rehabilitation, function is regained within 3 months.

Correct Answer: 3

77 of 100 The nurse is preparing for the admission of a client with a diagnosis of early stage Alzheimer's disease. The nurse assists in developing a plan of care, knowing that which is a characteristic of earlyAlzheimer's disease? 1. Confusion 2. Wandering 3. Forgetfulness 4. Personality changes

Correct Answer: 3

94 of 100 A client has an impairment of cranial nerve II. Specific to this impairment, the nurse plans to do which to ensure client safety? 1. Speak loudly to the client. 2. Place the client on aspiration precautions. 3. Provide a clear path for ambulation without obstacles. 4. Prohibit intensely smelling foods such as onions and tuna. Incorrect

Correct Answer: 3

97 of 100 The nurse has instructed the client with myasthenia gravis about ways to manage his or her own health at home. The nurse determines that the client needs further teaching if the client makes which statement? 1. "Here's the Medic-Alert bracelet I obtained." 2. "I should take my medications an hour before mealtime." 3. "Resting in a sauna will be a relaxing form of activity." 4. "I've made arrangements to get a portable resuscitation bag and home suction equipment."

Correct Answer: 3

56 of 100 The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure (ICP) if the nurse observes the client doing which activity? 1. Blowing the nose 2. Isometric exercises 3. Coughing vigorously 4. Exhaling during repositioning

Correct Answer: 4

71 of 100 Acetazolamide is prescribed for a client with a diagnosis of a supratentorial lesion. The nurse monitors the client for effectiveness of this medication, knowing which is its primary action? 1. Prevent hypertension 2. Prevent hyperthermia 3. Decrease cerebrospinal fluid production 4. Maintain an adequate blood pressure for cerebral perfusion

Correct Answer: 3

73 of 100 A client with right leg hemiplegia is experiencing difficulty with mobility. The nurse determines that there is a need for further teaching if the nurse observes which action by the family? 1. Applying a premolded splint 2. Performing active ROM to the affected leg 3. Encouraging the client to stand unassisted on the leg 4. Providing passive range of motion (ROM) to the affected leg

Correct Answer: 3

73 of 100 A client with right leg hemiplegia is experiencing difficulty with mobility. The nurse determines that there is a need for further teaching if the nurse observes which action by the family? 1. Applying a premolded splint 2. Performing active ROM to the affected leg 3. Encouraging the client to stand unassisted on the leg 4. Providing passive range of motion (ROM) to the affected leg

Correct Answer: 3

86 A client is suspected of having a diagnosis of Guillain-Barré syndrome (GBS). Which findings would support a diagnosis of Guillain-Barré syndrome? Select all that apply. 1. Permanent paralysis of the legs 2. Visual and hearing disturbances 3. Decreased level of consciousness 4. Decreased intellectual functioning 5. Ascending symmetrical muscle weakness

Correct Answer: 2, 5

60 of 100 A client with Parkinson's disease is embarrassed about the symptoms of the disorder and is bored and lonely. The nurse should plan which approach as therapeutic in assisting the client to cope with the disease? 1. Plan only a few activities for the client during the day. 2. Cluster activities at the end of the day when the client is most bored. 3. Encourage and praise perseverance in exercising and performing ADL. 4. Assist the client with activities of daily living (ADL) as much as possible.

Correct Answer: 3

The nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which measure should the nurse avoid in planning for the client's safety?

put a padded tongue blade at the head of the bed

The nurse is suctioning an unconscious client who has a tracheostomy. The nurse should avoid which action during this procedure?

suctioning for longer than 30 seconds