Nursing - Functional Ability

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 client comes to the emergency room (ER) complaining of weakness, dizziness, and difficulty breathing. The nurse performs an electrocardiogram (ECG) and notices this arrhythmia. Which arrhythmia is the client exhibiting?

Atrial fibrillation (AF)

A client suspected of having myasthenia gravis is scheduled for an edrophonium chloride (Tensilon) test. To treat a common complication associated with the test, the nurse should have what drug available?

Atropine (Atro-Pen)

The nurse is having difficulty understanding a client's decision to have hospice care rather than an extensive surgical procedure. Which ethical principle does the client's behavior illustrate?

Autonomy

A client is diagnosed with myasthenia gravis, and the anticholinesterase medication pyridostigmine (Mestinon) is prescribed. When teaching the client about this medication, the nurse explains that the desired effect is to increase:

Contraction of skeletal muscles

A client is undergoing diagnostic testing to determine if the client has myasthenia gravis. The nurse understands that the test that is most specific for determining the presence of this disease is:

Edrophonium chloride (Tensilon) test

A client is admitted to the hospital with a tentative diagnosis of Guillain-Barré syndrome. Which question by the nurse best will elicit information that supports this diagnosis?

"Have you experienced an infection recently?

A child is to receive 60 mg of phenytoin (Dilantin). The medication is available as an oral suspension that contains 125 mg/5 mL. How many milliliters should the nurse administer? Record the answer using one decimal place. ____ mL

2.4

The nurse has provided teaching to a client with impaired balance who uses a walker when ambulating. The nurse observes the client transferring from a sitting to a standing position and using the walker. The nurse evaluates that further teaching is required when the client:

Holds both handles of the walker while rising to the standing position

A client with myasthenia gravis experiences generalized weakness. What is most important when planning this client's nursing care?

Providing frequent rest periods

A client with early-stage cancer of the esophagus is treated with laser therapy. What type of food should the nurse instruct the client to select when oral intake is permitted?

Pureed

Clients who have casts applied to the lower extremities must be monitored for complications. Which finding during assessment of the extremities of these clients is indicative of a complication? Select all that apply.

Numbness Prolonged capillary refill

Which statement made by the client indicates correct understanding of gastroesophageal reflux disease (GERD) management?

"I will place a 6-inch block under the head of my bed to help with digestion

After becoming incontinent of urine, an older client is admitted to a nursing home. The client's rheumatoid arthritis contributes to severely painful joints. The primary consideration in the care of this client is the need for:

Control of pain

A client is suspected of having myasthenia gravis. What are the most significant initial nursing assessments that should be performed?

Effectiveness of respiratory exchange and ability to swallow

The nurse is caring for a client with rheumatoid arthritis. When should the nurse expect the client to experience increased pain and limited movement of the joints?

In the morning on awakening

After abdominal surgery a goal is to have the client achieve alveolar expansion. The nurse determines that this goal is most effectively achieved by:

Incentive spirometry.

A client is admitted to the hospital for an acute episode of rheumatoid arthritis. During the initial assessment, the nurse observes that the client's finger joints are swollen. To what does the nurse most likely attribute this swelling?

Inflammation in the joint's synovial lining

A client is admitted to the hospital with the diagnosis of Parkinson disease. What medication should the nurse expect the health care provider to prescribe to relieve the client's physiological responses to this disease?

Levodopa (l-Dopa)

Which common initial clinical effects should the nurse expect a client with multiple sclerosis to exhibit? Select all that apply.

Nystagmus Scanning speech Intention tremors

A client is admitted to the hospital with a diagnosis of emphysema and dyspnea. The nurse should encourage the client to assume what position?

Orthopneic

A nurse is caring for a client with Guillain-Barré syndrome. The nurse should prepare the client for what essential care related to rehabilitation?

Physical therapy

A client with myasthenia gravis has increased difficulty swallowing. How can the nurse prevent the aspiration of food?

Schedule meals with the peak effect of an anticholinesterase muscle stimulant

A nurse identifies that a client exhibits the characteristic gait associated with Parkinson disease. When recording on the client's record, the nurse documents this gait as:

Shuffling

An older female client who is confused and often does not recognize her children is admitted to a nursing home. The client appears slovenly, often soiling her clothing with feces and urine. How can the nurse best manage this problem?

Toileting the client every 2 hours

A client with painful swelling of a distal joint of the ring finger is found to be in the early stages of rheumatoid arthritis (RA). A test for the rheumatoid factor is negative. The client asks about the reliability of the test, stating, "I don't think the result is accurate. I have been diagnosed with RA, and I am in so much pain." How should the nurse respond?

"Laboratory tests often are negative in the early stages of the disease."

Nursing intervention for a client who is hyperventilating should focus on providing reassurance and:

Having the client breathe into a paper bag

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 client who had several episodes of chest pain is scheduled for an exercise electrocardiogram. Which explanation should the nurse include when teaching the client about this procedure?

"This is a noninvasive test to check your heart's response to physical activity."

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 staff member tells a nurse that an older client becomes irritable when asked to assist with activities of daily living. On what general information about older adults should the nurse base a response?

Decreased ability to cope

A nurse completes an admission assessment on a client who is diagnosed with myasthenia gravis. Which clinical finding is the nurse most likely to identify?

Difficulty swallowing saliva

The nurse frequently provides care for clients with hearing aids. The nurse recalls that the condition that best responds to hearing aids is:

Diminished sensitivity of the cochlea

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 nurse may find that, for optimum nutrition, a client with a cerebrovascular accident (also known as "brain attack") needs assistance with eating. What should the nurse do?

Encourage the client to participate in the feeding process

What should the nurse instruct family members to do to help an aphasic client regain as much speech function as possible?.

Encourage the client to speak while being patient with the attempts.

A nurse is caring for a client who will have a below-the-knee amputation with an immediate postoperative prosthesis. The client asks the nurse the advantage of having an immediate prosthesis. What should the nurse explain is the advantage?

Encourages a normal walking pattern

A client is diagnosed with myasthenia gravis. Which response does the nurse expect the client to demonstrate?

Fluctuating weakness of muscles innervated by the cranial nerves

An active adolescent is admitted to the hospital for surgery for an ileostomy. When planning a teaching session about self-care, the nurse includes sports that should be avoided by a client with an ileostomy. Which should be included on the list of sports to be avoided? Select all that apply.

Football Ice hockey

A college basketball player complains of a "click" in the knee when the client walks. The client states that the knee occasionally gives way when the client runs and sometimes locks. The client does not recall any specific injury. The nurse suspects that the diagnostic tests will reveal:

Injured cartilage in the knee

A client with a diagnosis of bipolar I disorder, depressive episode, is receiving lamotrigine (Lamictal). The nurse concludes that the medication is effective when the client becomes:

Involved in performing activities of daily living

A nurse prepares to administer metformin (Glucophage XR) to an older adult who has asked that it be crushed because it is difficult to swallow. The nurse explains that this drug cannot be crushed because it:

Is released slowly.

A nurse is administering medications to clients on a psychiatric unit. What does the nurse identify as the reason that so many psychiatric clients are given the drug benztropine (Cogentin) or trihexyphenidyl in conjunction with the phenothiazine derivatives neuroleptic medications?

It combats the extrapyramidal side effects of the other drug.

A nurse is assessing a client with Parkinson disease. Which assessment finding indicates the presence of bradykinesia?

Lack of spontaneous movement

During an interview a 32-year-old man describes symptoms of decreased appetite, insomnia, anhedonia, and feelings of worthlessness that have been present for the past few weeks. He reports having had a few episodes of feeling depressed in the past but says that the feelings subsided. Recently he has felt worse, and he is now concerned that his symptoms are negatively affecting his job performance and fears he may lose his job "if someone doesn't help me soon." The nurse suspects these symptoms are related to:

Major depressive disorder

A client with a history of Parkinsonism recently has developed rigidity, tremors, and signs of pneumonia. The client is hospitalized for treatment. The nursing plan of care should include:

Passive range-of-motion exercises at least every eight hours

Which information should be included in the teaching plan for the client diagnosed with epilepsy?

People taking phenytoin (Dilantin) must floss regularly

What nursing action is essential when a client experiences hemianopsia as the result of a left ischemic stroke?

Place objects within the visual field.

A client who is a carpenter reports increasing difficulty holding the tools needed to perform the carpentry skills. Assessment findings reveal carpel tunnel syndrome. The client states, "I must return to work tomorrow. I can't get behind on my schedule." Considering the client's statements, the nurse concludes that the issue of most concern is:

Potential for injury

The nurse who is teaching the client with chronic obstructive pulmonary disease (COPD) to use pursed-lip breathing (PLB) is aware that this is beneficial for the client through which mechanism?

Prolonged exhalation to decrease air trapping

A nurse enters the room of a client with myasthenia gravis and identifies that the client is experiencing increased dysphagia. What should the nurse do first?

Raise the head of the bed.

A client with a 5-year history of myasthenia gravis is admitted to the hospital because of an exacerbation. When assessing the client, the nurse identifies ptosis, dysarthria, dysphagia, and muscle weakness. The nurse expects what client response?

Strength decreases with repeated muscle use

When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance?

Suction as needed

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

The nurse assesses for damage to the glossopharyngeal (ninth cranial) and vagus (tenth cranial) nerves by testing the client's ability to:

Swallow

Which function must be addressed in the plan of care when a client has dysphagia?

Swallowing

After cataract surgery the nurse teaches a client how to self-administer eye drops. The nurse reinforces the use of what technique?

Holding the dropper tip above the conjunctival sac

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

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

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."