RN Targeted Medical Surgical Neurosensory and Musculoskeletal

A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect?

Impulsive behavior The nurse should expect clients who had a right hemispheric stroke to demonstrate impulsive behavior, poor judgment, and lack of awareness of neurologic deficits.

A nurse is assessing a client who is quadriplegic following a cervical fracture at the vertebral level C5. The client reports throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/110 mm Hg. Which of the following actions should the nurse take first

Elevate the head of the clients bed These assessment findings indicate that the client is experiencing autonomic dysreflexia and is at greatest risk for possible rupture of a cerebral vessel or increased intracranial pressure. The first action the nurse should take is to move the client from a supine to an upright position, which will result in rapid postural hypotension.

A nurse is planning care for a client following a lumbar puncture. Which of the following actions should the nurse plan to take

Ensure the client lays flat for up to 12 hrs The client should lie flat for up to 12 hr to prevent cerebrospinal fluid leakage from the puncture site, which can cause a headache.

A nurse is caring for a client who has a history of a status epilepticus ad requires seizure precautions. Which of the the following actions should the nurse take

Establish IV access The nurse should plan to establish IV access with a large-bore catheter and administer 0.9% sodium chloride if seizures are imminent. If the client is stable, the nurse should initiate a saline lock.

A nurse is caring for a client who has retinal detachment. Which of the following findings should the nurse expect?

Flashes of bright light The nurse should expect a client who has a retinal detachment to see flashes of bright light or floating dark spots in the affected eye as the retinal layers separate.

A nurse is caring for a client who has multiple scerolsis. Which of the following findings should the nurse expect?

Intention tremors Clients who have multiple sclerosis are at risk for motor dysfunction, with intention tremors, poor coordination, and loss of balance.

A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect?

Ulnar deviation A client who has rheumatoid arthritis can experience inflammation in the hand joints that can make them susceptible to deformity from daily use. Ulnar deviation, or lateral deviation of the fingers, can occur from opening jars and other similar motions.

A nurse is reviewing postoperative instructions with a client following cataract surgery. Which of the client statements indicates an understanding of the instructions?

"I should call my doctor is my vision gets worse" The client should expect an improvement in vision after the surgery, so the nurse should instruct the client to report negative changes in vision immediately.

A nurse is teaching a client who has multiple sclerosis and has a new prescription for glatiramer acetate. Which of the following statements indicates that the client understand the teaching

"I will avoid going to the store when it is crowded" Clients who are prescribed this medication are instructed to avoid crowds and individuals who have infection.

A nurse is developing a teaching plan for a client who has Meniere's disease. Which of the following instructions should the nurse include?

"Move your head slowly to decrease vertigo" The nurse should instruct the client to use slow head movements to keep from worsening the vertigo.

A nurse is teaching a client who has osteoporosis an has a new prescription for aledronate. Which of the following information hold the nurse include in the teaching?

"Remain upright for 30 minutes after taking this medication" To prevent esophagitis or esophageal ulcers, which can result from alendronate therapy, the client should sit upright for 30 min after taking this medication.

A nurse in an emergency department is caring for a client who suddenly lost consciousness and fell at home. The provider determines that the client had an embolic stroke. Which of the following medications should the nurse expect to administer

Tissue plasminogen activator Tissue plasminogen activator is a thrombolytic agent that should dissolve the blood clot that caused the stroke.

A nurse us caring for a client who has viral meningitis. Which of the the following actions should the nurse take?

Check capillary refill at least every 4 hr The nurse should perform a complete vascular assessment at least every 4 hr to monitor for vascular compromise.

A nurse us caring for a client who is in balanced suspension skeletal traction and reports intermittent muscle spasms. Which of the following actions should the nurse take first?

Check the position of the weights and ropes The first action the nurse should take when using the nursing process is to assess the client. The nurse should first check the position of the weights and ropes to investigate the cause of the muscle spasms. The weights might be too heavy, or the nurse might need to realign the client.

A nurse is performing a pain assessments for a client who is postoperative. Which of the following findings should the nurse use to determine the severity of the clients pain

Clients report of pain on a pain scale The nurse should use a client's report of pain on a standardized pain scale to determine the severity of the client's pain.

A nurse is planning care for a client who has a close traumatic injury form a fall and is receiving mechanical ventilation. Which of the following interventions is the nurses priority?

Maintain a PaCO2 of approximately 35 mm Hg The greatest risk to this client is injury from increased intracranial pressure. Therefore, the nurse's priority intervention is to maintain the PaCO2 at 35 to 38 mm Hg to prevent hypercarbia and subsequent vasodilation that can lead to an increase in intracranial pressure.

A nurse us caring for a client who has advancing amyotrophic lateral sclerosis. Which of the following interventions is the nurses priority?

Monster pulse oximetry findings The greatest risk to the client is respiratory compromise due to progressive paralysis of respiratory muscles. Therefore, the priority intervention is to monitor the client's oxygen saturation to identify respiratory compromise as soon as possible.

A nurse is teaching an assistive personnel about providing care to a client following a total hip arthroplasty. Which of the following instructions should the nurse include?

Place the abductor pillow between the client's legs when turning the client. The client should lie flat for up to 12 hr to prevent cerebrospinal fluid leakage from the puncture site, which can cause a headache.

A nurse us caring for a client who has a spastic bladder following a spinal cord injury. Which of the following action should the nurse take to help stimulate micturition?

Stroke the clients inner thigh The nurse should stimulate micturition by stroking the client's inner thigh. Other techniques include pinching the skin above the groin and providing digital anal stimulation.

A nurse is planning to teach a client who has epilepsy and and new prescription for phenytoin. Which of the following instructions should the nurse plan to include?

Take the medications at a consistent times each day to maintain therapeutic blood levels The nurse should teach the client to take antiepileptic medications on a regular schedule to maintain therapeutic blood levels and achieve the maximum effect.

A nurse is teaching a client and her family about the diagnosis and the treatment of Alzheimer's disease. Which of the following statements should the nurse identify as an indication that the family understands the teaching

"The medications that treat Alzheimer's disease can help delay cognitive changes Medications that treat Alzheimer's disease enhance the availability of acetylcholine, which can slow cognitive decline in some clients.

A nurse is caring for a client who is 72 hr postoperative following an above the knee amputation and reports phantom limb pain. Which of the following actions should the nurse take?

Request a prescription for gabapentin for the client The nurse should request a prescription for a nonopioid medication to help minimize phantom limb pain. Gabapentin is an oral antiepileptic medication that is effective for treating sharp, burning, phantom limb pain.

A nurse in an emergency department is caring for a client who has sustained a fracture of the femur following a motor-vehicle crash. Which of the following images should the nurse recognize as a comminuted fracture?

This is an image of a comminuted fracture, in which the injury causes the bone to fragment into several pieces.

A nurse I teaching a client who has Parkingson's disease and is prescribed carbidopa-levodopa. Which of the following client statements indicates a n understanding if the teaching?

"I should erect this medication to cause me to be drowsy" Drowsiness is a known adverse effect of carbidopa-levodopa; therefore, clients are taught to avoid heavy machinery and driving if they experience drowsiness.

A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider?

Clear discharge from nose Clear drainage from the nose indicates that cerebrospinal fluid is leaking from the skull fracture. This places the client at risk for meningeal infection because micro-organisms have access to the cranium through the nose and the tear in the dura. The nurse should report this finding to the provider.

A nurse is assessing a client who has a head injury following a motor vehicle crash. The nurse should identify which of the following indicated increasing intracranial pressure?

Restlessness Behavioral changes, such as restlessness and irritability, are early manifestations of increased intracranial pressure.

A nurse in the emergency department is assessing a client who reports sudden, severe eye pain with blurred vision. The provider determines the client has primary angle-closure glaucoma. What should the nurse administer?

Osmotic diuretics via IV bolus The nurse should expect to administer prescribed osmotic diuretics, such as mannitol, to reduce intraocular pressure and prevent damage to the eye.

A nurse is assessing a client who has a new diagnosis of osteoarthritis. Which of the following findings should the nurse expect (select all that apply)

Crepitus with joint movement is correct. Osteoarthritis is a degenerative joint disease. Crepitus, a grating sound, is an expected finding with clients who have osteoarthritis as loosened bone and cartilage move around in the fluid inside the joint. Decreased range of motion of the affected joint is correct. Decreased range of motion is an expected finding with clients who have osteoarthritis because the client's pain limits movement. Low-grade fever is incorrect. Osteoarthritis does not cause systemic manifestations. Rheumatoid arthritis causes many systemic manifestations, including low-grade fever, weakness, anorexia, and paresthesias. Spongy tissue over the joints is incorrect. Spongy joint tissue is an expected finding with rheumatoid arthritis, which is an inflammatory disease, not a degenerative disease. Joint pain that resolves with rest is correct. Joint pain that resolves with rest is an expected finding with clients who have osteoarthritis. A client who has osteoarthritis experiences increased pain with activity and decreased pain with rest.

A nurse is caring for a client who is recovering from a stroke and has right sided homonymous hemianopsia. To help the client adapt to the hemianopsia, the nurse should take which of the following actions?

Remind the client to look consciously at both sides of their meal tray Clients who have right-sided homonymous hemianopsia have lost the right visual field of both eyes and might only eat the food they are able to see on the left half of the meal tray. Therefore, the nurse should remind the client to look at both sides of his meal tray to help compensate for the visual loss.