Targeted Neurosensory and Musculoskeletal ATI Exam

A nurse is providing teaching regarding a new prescription for carbidopa-levodopa for a client who has Parkinson's disease. Which of the following client statements indicates an understanding of the teaching? 1) I should expect an increase in BP 2) I should take this medication 2 hours after meals to increase absoprtion 3) I should expect that this medication can cause me to be drowsy 4) I should expect this medication to be effective within 48 hours

"I should expect that this medication can cause me to be drowsy"

A nurse is teaching a client who has multiple sclerosis and has a new prescription for glatiramer acetate. Which of the following statements indicated that the client understand the teaching? 1) "I will ask my partner to give the injection in the same spot each time." 2) "I will avoid going to the store when it is crowded." 3) "I will see relief of my symptoms in about 1 week." 4) "I will exercise rigorously while taking this medication."

"I will avoid going to the store when it is crowded." *avoid people with infections

A nurse is providing teaching for a client and his family about the diagnosis and treatment of Alzheimer's disease. Which of the following statements by the familly indicates an understanding of the teaching? 1) "there is a test for alzheimer's disease that can establish a reliable diagnosis" 2) "the goal of medication therapy is to reverse the degenerative changes that can occur in brain tissue" 3) "early manifestations of Alzheimer's disease include mild tremors and muscular rigidity" 4) "the medications that treat Alzheimer's disease can help delay cognitive changes"

"The drugs used to treat Alzheimer's disease can help delay cognitive changes."

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? 1) Hypoactive deep-tendon reflexes 2) Ascending paralysis 3) Intention tremors 4) Increased lacrimation

3

A nurse is performing a pain assessment on a postoperative client. Which of the following should the nurse use to determine the severity of the client's pain? 1) Client's vital sign changes 2) Client's report of the type of pain 3) Client's nonverbal communication 4) Client's report of pain on a pain scale

4

A nurse is teaching an AP about providing care to a client following a total hip arthroplasty. Which of the following instructions should the nurse include? 1) avoid applying TED hose to the affected leg 2) have the client lean forward when moving from sitting to standing 3) discourage the client from sitting in a wheelchair with the back reclined 4) place an abductor pillow between the client's legs when turning the client

4

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? 1) Glasgow Coma Scale score of 15 2) Intracranial pressure reading of 15 mm Hg 3) Ecchymosis at base of skull 4) Clear drainage from nose

4 *CSF is leaking from the fracture

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? 1) remind the client that the surgery removed the limb 2) change the dressing on the client's residual limb 3) request a prescription for gabapentin for the client 4) elevate the client's residual limb above the level of the heart

Administer an oral dose of gabapentin to the client. R: gabapentin is an anti-epileptic medication and is effective for treatment of phantom limb pain

A nurse is caring for a client in balanced suspension skeletal traction who reports intermittent muscle spasms. Which of the following actions should the nurse take first? 1) reposition the client 2) Check the position of the weights and ropes 3) administer a muscle relaxant 4) provide distraction

Check the position of the weights and ropes.

A nurse is assessing a client who is quadriplegic secondary to a cervical fracture at vertebral level C5. The client reports a 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? 1) administer hydralazine IV bolus 2) loosen the client's clothing 3) empty the client's bladder 4) elevate the head of the client's bed

Elevate the head of the client's bed.

A nurse is planning care for a client following a lumbar puncture. Which of the following actions should the nurse plan to include? 1) apply a pressure dressing to the site for 8 hours 2) restrict the client's fluid intake for 24 hours 3) ensure that the client lies flat for up to 12 hours 4) inform the client that neck stiffness is an expected outcome of the procedure

Ensure the client lies flat for up to 12 hours *to prevent cerebrospinal fluid leakage from the puncture site

A nurse is caring for a client who was admitted for status epilepticus and is on seizure precaution. Which of the following actions should the nurse plan to take? 1) assess hourly for a spike in BP 2) keep the client on bedrest 3) keep a padded tongue blade at the bedside 4) establish IV access

Establish IV access.

A nurse is caring for a client who has a retinal detachment. Which of the following reports about the affected eye should the nurse expect? 1) photophobia 2) complete vision loss 3) flashes of bright light 4) cloudiness of the lens

Flashes of bright light.

A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect? 1) aphasia 2) right-sided neglect 3) impulsive behavior 4) inability to read

Impulsive behavior

A nurse is caring for a client who has viral meningitis. Which of the following actions should the nurse take? 1) assess neurologic status every 8 hours 2) initiate droplet precautions 3) check cap refill at least every 4 hours 4) place the client in a well-lit enviroment

Monitor capillary refill at least every 4 hr.

A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which of the following interventions is the nurse's priority? 1) provide frequent rest periods throughout the day 2) administer pain medication on a regular schedule 3) monitor pulse oximetry findings 4) administer baclofen for spasticity

Monitor pulse oximetry findings. *the greatest risk to this client is respiratory compromise due to progressive paralysis of respiratory muscles

A nurse is developing a teaching plan for a client who has Meniere's disease. Which of the following instructions should the nurse include? 1) move your head slowly to decrease vertigo 2) apply warm packs to the affected eat during acute attacks 3) increase your intake of foods and fluid high in salt 4) take corticosteroids during acute attacks

Move head slowly to decrease vertigo. *so vertigo doesn't get worse

A nurse is caring for a client who is recovering from a stroke and has right-sided homonymous hemianopsia. To help the client adapt, the nurse should take which of the following actions? 1) check the client's cheek on the affected side after meals to be sure no food remains there 2) encourage the client to sit upright with their head tilted slightly forward during meals 3) provide the client with eating utensils that have large handles 4) Remind the client to look consciously at both sides of his meal tray.

Remind the client to look consciously at both sides of his meal tray.

A nurse is assessing a client who has a possible head injury following a motor-vehicle crash. The nurse should recognize that which of the following findings indicates increasing intracranial pressure? 1) restlessness 2) dizziness 3) hypotension 4) tachycardia

Restlessness.

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. Which of the following medications should the nurse administer? 1) osmotic diuretics via IV bolus 2) mydriatic ophthalmic drops 3) corticosteroid drops 4) epinephrine via IV bolus

Osmotic diuretics via IV bolus.

A nurse is reviewing postoperative instructions with a client following cataract surgery. Which of the following client statements indicates an understanding of instructions? 1) I should call the doctors if my vision gets worse 2) I will take aspirin for eye discomfort 3) I can blow my nose to clear out drainage 4) I can lift objects up to 20 pounds

I should call my doctor if I experience a decrease in my vision.

A nurse is planning care for a client who has closed head injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurse's priority? 1) Maintain a PaCO2 of approximately 35 mm Hg. 2) provide small doses of fentanyl via IV bolus for pain management 3) measure body temp every 1-2 hours 4) reposition client every 2 hr

Maintain a PaCO2 of approximately 35 mm Hg.

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.) 1) crepitus with joint movement 2) decreased ROM of affected joint 3) low-grade fever 4) spongy tissue over the joints 5) joint pain that resolves with rest

- Crepitus with joint movement. - Decreased range of motion of the affected joint. - Joint pain that resolves with rest.

A nurse is providing teaching for a client who is prescribed alendronate for osteoporosis. Which of the following information should the nurse include in the teaching? 1) take the medication with 8 oz of milk 2) remain upright for 30 minutes after taking this medication 3) wait 1 hours after taking other medications to take alendronate 4) take vitamin C to promote absorption of this medication

Remain upright for 30 min after taking this medication.

A nurse is caring for a client who has a spastic bladder following a spinal cord injury. Which of the following actions should the nurse take to help stimulate micturition? 1) encourage the client to use the valsalva maneuver 2) stroke client's inner thigh 3) perform the crede maneuver 4) administer a diuretic

Stroke the client's inner thigh.

A nurse is teaching a client who has epilepsy and is to start therapy with phenytoin. Which of the following instructions should the nurse include in the client's medication teaching plan? 1) rinse with mouthwash instead of using floss 2) use an OTC antihistamine if rash develops 3) slowly taper the medication after 6 months with seizure activity 4) take medications at a consistent time each day to maintain therapeutic blood levels

Take medications at a consistent time each day to maintain therapeutic blood levels.

A nurse is assessing a client who has rheumatoid arthritis. Which of the following assessment findings should the nurse expect? 1) unilateral joint involvement 2) ulnar deviation 3) fractures of the spine 4) decreased sedimentation rate

Ulnar deviation.

A nurse in the emergency department is caring for a client after suddenly losing consciousness and falling in her home. The provider determines the client had an embolic stroke. Which of the following medications should the nurse administer? 1) tPa 2) recombinant factor VIII 3) nitroglycerin 4) lidocaine

tPa