NCLEX book Managing Care, Quality, and Safety of Clients with Neurologic Health Problems

2. Reposition client every 2 hours.

113. When caring for a client with Guillain-Barre syndrome, the nurse can delegate which activity to the unlicensed assistive personnel (UAP)? 1. Assess weakness with range-of-motion exercises. 2. Reposition client every 2 hours. 3. Suction the endotracheal tube. 4. Show the client how to do deep-breathing exercises.

3. pulling up the client under the left shoulder when getting the client out of bed to a chair

114. An unlicensed assistive personnel (UAP) is providing care to a client with left-sided paralysis. Which action by the UAP requires the nurse to provide further instruction? 1. providing passive range-of-motion exercises to the left extremities during the bed bath 2. elevating the foot of the bed to reduce edema 3. pulling up the client under the left shoulder when getting the client out of bed to a chair 4. putting high top tennis shoes on the client after bathing

4. A 63-year-old with multiple sclerosis who has an oral temperature of 101.8° F (38.8° C) and flank pain.

116. After receiving a change of shift report at 0700, the nurse should assess which client first? 1. a 23-year-old with a migraine headache who has severe nausea associated with retching 2. A 45-year-old who is scheduled for a crainiotomy in 30 minutes and needs preoperative teaching will need a swallowing assessment before 3. a 59-year-old with Parkinson's disease who will need a swallowing assessment before breakfast 4. a 63-year-old with multiple sclerosis who has an oral temperature of 101.8F (38.8 C) and flank pain.

1. ankles 2. ear 3. greater trochanter 7. shoulder

118. Which pressure point areas should the nurse monitor for an unconscious client positioned on the left side? (See figure.) Select all that apply. 1. ankles 2. ear 3. greater trochanter 4. heels 5. occiput 6. sacrum 7. shoulder

3. Increase the frequency of client observation.

120. The nurse is caring for a client who is confused about time and place. The client has intravenous fluid infusing. The nurse attempts to reorient the client, but the client remains unable to demonstrate appropriate use of the call light. In order to maintain client safety, what should the nurse do first? 1. Ask the family to stay with the client. 2. Contact the healthcare provider (HCP), and request a prescription for soft wrist restraints. 3. Increase the frequency of client observation. 4. Administer a sedative.