Neuro
Vasospasms can be treated with
Ca channel blockers
Stroke nursing mngmt. priority
Respiratory assessment
most common bowel problem
constipation. need stool softeners or fiber and physical activity
Stroke nursing mgnt.
neuro, cardio - vitals perfusion, ekg integumentary, gastro - bowel n bladder program
A nurse is precepting an orientee (newly hired nurse). The nurse observes the orientee caring for an unconscious client with increasing intracranial pressure. The nurse should question which intervention that the orientee performs? 1 Lubricating the skin with baby oil Correct 2 Suctioning the oropharynx routinely 3 Elevating the head of the bed 20 degrees 4 Cleansing the eyes every four hours with normal saline Although suctioning is done to maintain an airway, it is not done routinely because it increases intracranial pressure. The nurse should intervene to correct this behavior. All the rest are correct behaviors. Lubricating the skin keeps the skin from drying, which helps prevent skin breakdown. Elevating the head of the bed promotes venous return to the heart and is used to limit increased intracranial pressure. Instilling artificial tears every two hours is the appropriate intervention. The corneal reflex may be absent in the unconscious client; a dry cornea is prone to injury. 13266790913 Confidence: Nailed It Stats 3. A client is diagnosed with the genetic disorder osteogenesis imperfecta. Which condition can be anticipated in the client at an age of 30? Correct 1 Loss of auditory acuity 2 Loss of visual acuity 3 Loss of smell perception 4 Loss of touch perception Sone genetic disorders, such as osteogenesis imperfecta and Down syndrome, lead to progressive hearing loss in adults. Familial tendency and some genetic conditions may cause visual impairment. Osteogenesis imperfecta typically does not cause loss of smell or touch perception. 13267950547 Confidence: Nailed It Stats 4. Which clinical indicator does a nurse identify when assessing a client with hemiplegia? 1 Paresis of both lower extremities Correct 2 Paralysis of one side of the body 3 Paralysis of both lower extremities 4 Paresis of upper and lower extremities Hemiplegia is paralysis of one side of the body. Paresis is a weakness or partial paralysis. Paraplegia is the paralysis of both lower extremities and the lower trunk. Paresis of upper and lower extremities is quadriparesis. 13267908187 Confidence: Nailed It Stats 6. A nurse is caring for a client with a brain tumor in the occipital lobe. What clinical indicator does the nurse expect to identify when assessing the client? 1 Hemiparesis 2 Receptive aphasia 3 Personality changes Correct 4 Visual hallucinations The occipital lobe is involved with visual interpretation [1] [2]. Hemiparesis is not associated with the occipital lobe damage. Receptive aphasia is a function associated with the temporal lobe. Personality changes are functions associated with the frontal lobe. 13267102574 Confidence: Nailed It Stats 9. An older client is treated in the emergency department for soft-tissue injuries that the medical team suspects might be caused by physical abuse. An adult child states that the client is forgetful and confused and falls all the time. A mini-mental examination indicates that the client is oriented to person, place, and time, and the client does not comment when asked directly how the bruises and abrasions occurred. What is the next appropriate nursing action? Correct 1 Interview the client without the presence of family members. 2 Report the abuse to the appropriate state agency for investigation. 3 Accept the adult child's explanation until more data can be collected. 4 Refer the client's clinical record to the hospital ethics committee for review. Privacy may provide an environment that is conducive to the client sharing information about the situation. The client needs to be kept safe; this action ensures additional time for assessment to rule out the possibility of abuse. Reporting the abuse to the appropriate state agency for investigation is premature; further assessment is needed to determine if it is necessary to notify the appropriate agency. Accepting the adult child's explanation until more data can be collected will form a separate relationship with the adult child, which is not in the client's best interest. Referring the client's clinical record to the hospital ethics committee for review is inappropriate; this situation presents a legal, not ethical, issue. STUDY TIP: Becoming a nursing student automatically increases stress levels because of the complexity of the information to be learned and applied and because of new constraints on time. One way to decrease stress associated with school is to become very organized so that assignment deadlines or tests do not come as sudden surprises. By following a consistent plan for studying and completing assignments, you can stay on top of requirements and thereby prevent added stress. 13267176062 Confidence: Nailed It Stats 10. A nurse is assessing a client whose mouth is drooping over to the left. Which cranial nerve should the nurse assess further? Correct 1 Left facial nerve 2 Right facial nerve 3 Left abducens nerve 4 Right abducens nerve The facial nerve (seventh cranial) has motor and sensory functions. The motor function is concerned with facial movement, including smiling and pursing the lips. Nonconduction of the facial nerve will cause drooping on the side of the problem. Nonconduction of the facial nerve on the right side will cause that side of the face to droop. Nonconduction of the left abducens nerve will prevent abduction of the left eye. Nonconduction of the right abducens nerve will prevent abduction of the right eye. 13268090913 Confidence: Nailed It Stats 11. 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 makes which statement? 1 "I'll take an antihistamine at the first sign of a cold." 2 "I should skip a dose of pyridostigmine bromide (Mestinon) if it upsets my stomach." 3 "We've told our daughter not to let her cold keep her from visiting us." Correct 4 "The healthcare provider may need to adjust the dosage of my medication if I'm more active." Increased activity without an increase in medication can precipitate a myasthenic crisis [1] [2]. Self-medication may result in drug interactions; a change in medical therapy can have serious consequences. A dose should not be skipped because doing so may result in severe respiratory distress. People with myasthenia gravis should avoid crowds and others with colds; they are more prone to respiratory infections because of an ineffective cough and a potential for aspiration. Test-Taking Tip: Prepare for exams when and where you are most alert and able to concentrate. If you are most alert at night, study at night. If you are most alert at 2 am, study in the early morning hours. Study where you can focus your attention and avoid distractions. This may be in the library or in a quiet corner of your home. The key point is to keep on doing what is working for you. If you are distracted or falling asleep, you may want to change when and where you are studying.
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