Adult Health - Archer Review (4/8) - Neurologic and Environmental Emergencies

Choice A is correct. The expression of speech is controlled by Broca's area in the frontal lobe. Broca's area is in the left hemisphere near the motor strip.

A 45-year-old man on the neurology floor can understand instructions but is unable to express himself through talking. Which lobe of the brain controls the expression of speech? A. Frontal lobe B. Parietal lobe C. Temporal lobe D. Occipital lobe

Choice C is correct. This statement shows compassion toward the patient. Asking where the client and her sister grew up allows her to think about her sister and reminisce without triggering anxiety or agitation. When communicating with a patient who has altered mental status, such as those with dementia, it is essential to foster therapeutic communication. Any statement that may trigger agitation or begin the grieving process should be avoided.

A 76-year-old woman with dementia lives in an assisted living facility and often asks, "When will my sister come to visit me this afternoon?" The sister passed away last year. Which is the best response from the nurse? A. "This is so sad. I'm sorry to tell you but your sister died last year." B. "She won't be coming to visit today." C. "I understand you want her to visit you. Where did you and your sister grow up?" D. "Wait and see if she comes to visit today."

Choice B is correct. Approximately 60-70% of clients diagnosed with Guillain-Barré syndrome experienced the onset of symptoms approximately one to four weeks following a respiratory or gastrointestinal tract infection. Although the cause of Guillain-Barré syndrome is not fully understood, it is thought to be autoimmune.

A client is admitted with a possible diagnosis of Guillain-Barré syndrome. Which important question should the nurse include when taking this client's history? A. "Do you experience frequent bruising?" B. "Did you have a recent respiratory or gastrointestinal infection?" C. "Have you been overseas during the past four months?" D. "Has anybody in your family had Guillain-Barré syndrome?"

Choices A and D are correct. Neuropathic pain describes constant inflammation or irritation of nerve cells that causes pain sensation due to oversensitive nerve cells and a decrease in opioid receptors. Examples of neuropathic pain sources include CNS lesions, stroke, tumor, multiple sclerosis, sciatica, shingles, and phantom limb pain.

Of the following, which conditions would the nurse recognize as potential sources of neuropathic pain? Select all that apply. Spinal tumor Arthritic joint Muscle strain Shingles Kidney stones

Choice D is correct. Cluster breathing is associated with lesions of the medulla or lower pons. This breathing pattern is characterized by clusters of breaths with irregular pauses in between.

The ICU nurse assesses a comatose patient with a known lesion to the medulla. Which breathing pattern would the nurse expect to assess? A. Cheyne-Stokes B. Apneustic breathing C. Central neurogenic hyperventilation D. Cluster breathing

bacterial meningitis

The client is at highest risk for developing ____

traumatic brain injury.

The client is at highest risk of developing pulmonary embolism. right arm contracture. ischemic stroke. traumatic brain injury.

This client is experiencing a cluster headache. Cluster headaches have an abrupt onset, are more common in men, and are episodic.

The client is demonstrating clinical manifestations consistent with cluster headache tension headache trigeminal neuralgia migraine headache

Choice A is correct. Visual disturbances are expected for a client with a stroke impacting the occipital lobe of the brain. The occipital lobe is the primary optical center of the brain. Homonymous hemianopia is a complete left or right visual field defect. The client may need to be taught to scan the room, and the nurse should place objects in the unaffected visual field.

The nurse cares for a client who sustained a stroke impacting the occipital lobe. Which of the following assessment findings would support this diagnosis? A. homonymous hemianopia B. impaired proprioception C. expressive aphasia D. impulsivity

Choice D is correct. Bell's palsy is a lower motor neuron facial nerve palsy that can result in the weakness of facial muscles and the muscles responsible for eye closure (orbicularis oculi). A client with Bell's palsy who cannot blink would be unable to close the affected eye. As a result, the cornea becomes overly dry, leading to an increased risk of corneal ulceration and scarring. Eye lubricant (i.e., typically artificial tears) must be applied as often as every hour during the day to keep the eye moist and prevent corneal drying. A moisturizing eye ointment may be used at night.

The nurse is caring for a client who has had an exacerbation of Bell's palsy. The client is experiencing paralysis of their eye, the nurse should plan to A. tape an eye patch to the affected eyelid at all times. B. instruct the client to keep both eyes closed. C. assess the pupil's size and reactivity to light. D. apply the prescribed ocular lubricant to the affected eye.

The RN is caring for a client who is recovering from carotid endarterectomy. Which assessment would the nurse recognize as a sign that the client experienced hypoglossal nerve injury? A. Tongue deviation B. Inspiratory stridor C. Tracheal deviation D. Severe headache

The RN is caring for a client who is recovering from carotid endarterectomy. Which assessment would the nurse recognize as a sign that the client experienced hypoglossal nerve injury? A. Tongue deviation B. Inspiratory stridor C. Tracheal deviation D. Severe headache

heat stroke

The client is most likely experiencing ____

Choices A, B, C, and E are correct. Early interventions for a client suspected of having a CVA is performing a focused neurological assessment, including a GCS (choice A). An NIH stroke scale is also performed. A capillary blood glucose is also performed to rule out hypoglycemia, as hypoglycemia manifestations (drowsiness, slurred speech) may mimic stroke manifestations (choice B). There are two types of stroke - ischemic or hemorrhagic. The management differs based on the type of stroke. An ischemic stroke may be treated with thrombolytic therapy, whereas thrombolytics are contraindicated in a hemorrhagic stroke. An immediate head CT scan, without contrast, is initially performed to exclude a hemorrhagic stroke (choice C). Later diagnostic testing includes a CT angiogram and magnetic resonance imaging (MRI). It is important to discern when the client's symptoms started (choice E). The last known well time (LKW) refers to the date and time at which the client was last known to be without the signs and symptoms of the present stroke. This information is critical for determining the client's eligibility for thrombolytic therapy (tPA) in an acute ischemic CVA. If tPA is prescribed, it must

The emergency department (ED) nurse cares for a client with a suspected cerebrovascular accident (CVA). Which actions should the nurse take? Select all that apply. Perform a Glasgow coma scale (GCS) Assess the client's capillary blood glucose (CBG) Prepare the client for an immediate computed tomography (CT) scan of the brain Insert a nasogastric tube (NGT) Determine the onset of the symptoms or the last known well (LKW)

Choice A is correct. Kernig's sign is positive if pain occurs upon extension of the knee. When meninges are inflamed (meningitis), movement of the spinal cord or nerves against the inflamed meninges results in pain. With the client placed supine and hip flexed at 90 degrees, an extension of the knee stretches the hamstring and triggers pain by pulling tissues surrounding an inflamed spinal canal and meninges.

The emergency department (ED) nurse triages a client with suspected bacterial meningitis. The nurse plans on assessing the client for Kernig's sign. The nurse understands that this sign is positive when the client A. reports pain when the knee is extended and the hip flexed. B. has stiff neck when the neck is flexed towards the chest. C. forearm spasms when a blood pressure cuff is inflated on the upper arm. D. reports pain in the calf when the foot is dorsiflexed.

Choice A is correct. Tourniquets should not be used in snake bites. The tourniquet impedes arterial blood flow and can be quite harmful to the extremity. The client should immobilize the affected extremity to decrease the absorption of the venom.

The newly hired nurse cares for a client bitten by a venomous snake in the left hand. Which of the following interventions by the newly hired nurse requires follow-up by the charge nurse? A. Applying a tourniquet proximal to the bite. B. Removing the client's wristwatch and jewelry. C. Establishing intravenous (IV) access. D. Obtaining a type and crossmatch for fresh frozen plasma (FFP).

Choice A is correct. Ptosis, or eye drooping, occurs with cranial nerve III (oculomotor) lesions, myasthenia gravis, and Horner syndrome. Dysfunction of cranial nerve III is also associated with dilated pupil, absent light reflex, and impaired extraocular muscle movement.

The nurse assesses a client with damage to cranial nerve III. Which finding would be expected? A. Ptosis B. Anosmia C. Uvula deviation D. Asymmetric facial movement

Choice B is correct. One of the major goals during a seizure is injury prevention. Caregivers should be taught about injury prevention precautions. The wife should ensure that the furniture is moved out of the way when her husband seizes, improving his safety.

The nurse gives discharge instructions to a client who sustained a brain injury from a motor vehicle accident. His wife is concerned regarding her husband having seizures at home. Which statement from the wife indicates that she understood the nurse's teaching? A. "I will make sure that my husband does not wet himself." B. "I will clear all furniture that might injure him when he has a seizure." C. "I will call 911 once he has a seizure lasting about 3 minutes." D. "I will ensure he sleeps well after a seizure."

The client is lethargic and makes no purposeful movements. Does not respond to physical stimuli. Glasgow coma scale 10.

The nurse implements the physician's orders and documents a follow-up nursing note 1100 - The client is lethargic and makes no purposeful movements. Does not respond to physical stimuli. Glasgow coma scale 10. Peripheral pulses 2+. The client's skin is pale and dry. Petechial rash on the torso. Vital signs: T 100.4° F (38° C), P 101, RR 12, BP 117/88, pulse oximetry reading 95%.

Choice B is correct. Rehabilitation should begin early in the client's treatment. This most often occurs in the acute or critical care unit once clients are hemodynamically stable. In some settings, case managers begin working with clients in the emergency department to establish a positive image of spinal cord injury rehabilitation.

The nurse in the neurology ward is caring for a paraplegic client secondary to a spinal cord injury. While preparing for the client's rehabilitation, which of the following would be the most appropriate to include in the client's care plan? A. The client and their family members will arrange for rehabilitation. B. The rehabilitation plan should be implemented early in the client's treatment. C. The client should plan for minimal and short-term rehabilitation, as they will return to their former activities. D. Long-term care should be arranged, as the client can no longer perform self-care.

Choice D is correct. Following hypophysectomy, the client is at risk of developing diabetes insipidus (DI). An hourly urine output of 125 mL would be considered polyuria because, in 24 hours, that would equate to 3000 mL. A hallmark of DI is polyuria and pale urine (low urine specific gravity).

The nurse is assessing a client who is postoperative following a hypophysectomy. Which of the following findings should the nurse report to the primary healthcare provider (PHCP) immediately? A. Client reports a decreased smell B. No bowel movement in two days C. Foul-smelling breath D. Hourly urine output of 125 mL

Choices A, C, and E are correct. Key clinical features of myasthenia gravis (MG) include diplopia, ptosis, facial muscle weakness, and may progress to respiratory failure. Some of the earlier manifestations associated with MG are ocular.

The nurse is assessing a client who is suspected of having myasthenia gravis. Which of the following would be an expected finding? Select all that apply. Diplopia Butterfly rash Facial muscle weakness Shuffling gait Ptosis

Choice D is correct. Guillain Barré is a polyneuropathy manifested by paralysis, paresthesia, autonomic disturbances, and depressed or absent reflexes. The paresthesia is typically found in the peripheral extremities and may persist for quite some time, even after the return of motor function.

The nurse is assessing a client with Guillain Barré syndrome. Which of the following would be an expected finding? A. Hyperreflexia B. Perseveration C. Dystonia D. Paresthesia

Choice D is correct. With Werneckie's aphasia, the client is unable to understand the spoken and often the written word; however, their speech may have a normal rate, rhythm, and grammar. However, the content of what they speak may be jumbled or referred to as a word salad.

The nurse is assessing a client with Wernicke's aphasia. Which client finding would be consistent with this diagnosis? The client A. loss of ability to execute or carry out skilled movements. B. cannot express any words. C. cannot swallow liquids. D. speaks with normal fluency and prosody.

Choice B is correct. Irregular respiration, bradycardia, and widened pulse pressure are the three symptoms that makeup Cushing's triad. Cushing's triad occurs when the intracranial pressure in the skull has increased, thus causing these symptoms to happen. These manifestations are a late sign of increased intracranial pressure, where headache and altered level of consciousness are early signs.

The nurse is assessing a client with suspected Cushing's triad. Which of the following findings would support a diagnosis of Cushing's triad? A. hypotension, jugular venous distention, and muffled heart tones B. irregular respirations, bradycardia, and widening pulse pressure C. fixed pupils, hypotension, and bradycardia D. bradycardia, hypotension, and bradypnea

Choice B is correct. The lumbar puncture procedure may take up to 15-30 minutes. Following the procedure, the client is asked to lie flat for about one to two hours. Lying flat may reduce the intensity of post-lumbar puncture headache, although it may not prevent it. A need to urinate during or immediately after the procedure interrupts this protocol. Therefore, as an additional comfort measure, the client should be reminded to empty their bladder before the procedure begins. This should be the first action of the nurse.

The nurse is assisting the primary healthcare provider (PHCP) with a lumbar puncture to assess for meningitis. What should be the first action of the nurse? A. Lay the client on his side. B. Ask the client to void. C. Obtain an advanced directive from the client. D. Withhold food and drinks from the client prior to the procedure.

Choice B is correct. Log rolling, a position change in which the client turns as a single unit while keeping their back as straight as possible, is the priority for this client in order to maintain proper body alignment and prevent injury to the spinal cord. When performing a log roll maneuver, three staff members are required, with one staff member on each of the client's sides and one at the client's head. The staff member at the client's head is in charge of maintaining the integrity of the client's cervical spine while maintaining manual in-line spinal immobilization during the log roll.

The nurse is caring for a client eight hours postoperative following spinal surgery. Which action is essential for the nurse to take? A. Assess the client's pain while they receive patient-controlled analgesia (PCA) B. Log roll the client when turning the client from side to side C. Assist the client with ambulating to the bathroom D. Place pillows under the thighs of each leg when the client is supine

Choice B is correct. Acetazolamide, a carbonic anhydrase inhibitor, is commonly prescribed to prevent or treat AMS. It acts by causing a bicarbonate diuresis, which rids the body of excess fluid and induces metabolic acidosis. The acidotic state increases the respiratory rate and decreases the occurrence of periodic respiration during sleep at night. In this way, it helps clients acclimate faster to a high altitude. By increasing the client's respiratory rate, the client can perfuse more oxygen. It is preferred that this medication be taken 24 hours prior to the ascent.

The nurse is caring for a client experiencing acute mountain sickness (AMS). The nurse anticipates a prescription for which medication? A. Sodium bicarbonate B. Acetazolamide C. Tamsulosin D. Dutasteride

Choice C is correct. Many actions should be taken for a client experiencing vertigo, but protecting the client's safety is essential. If a client is experiencing vertigo, this raises the risk of a fall. Interventions to prioritize include adequate lighting in the bathroom, raising the upper side rails on the bed, and providing the client with the call bell, coupled with instructing the client to use it before getting out of bed.

The nurse is caring for a client experiencing an episode of vertigo. The nurse should plan to take which essential action? A. Avoid sudden movement changes B. Provide additional pillows to support the client's head C. Raise the upper side rails of the bed D. Instruct the client to move the head slowly

Choice C is correct. Difficulty swallowing liquids indicates nerve damage that requires immediate follow-up. Following cervical spinal surgery, the client is likely placed in a cervical collar for a prescribed period. Manifestations that need to be reported following cervical spinal surgery include numbness and tingling in the upper extremities, difficulty swallowing, decreased motor strength, and respiratory depression.

The nurse is caring for a client following cervical spinal surgery. Which of the following assessments would require follow-up? A. Active range of motion in both arms B. Scant drainage on the dressing C. Difficulty swallowing liquids D. Soreness at the operative site

Choice A is correct. Respiratory rate is essential to monitor when a cervical spinal cord injury is sustained. The upper cervical spinal nerves innervate the diaphragm to control breathing. Thus, specific injuries to the cervical spinal cord could be catastrophic.

The nurse is caring for a client who sustained a cervical spinal cord injury. Which priority vital sign should the nurse obtain? A. Respiratory rate B. Blood Pressure C. Pulse D. Temperature

Choice B is correct. Permissive hypertension during an ischemic stroke allows the blood pressure to go up to 185/110 mm Hg. This enables perfusion around the stroke to distal tissue. Thus, the nurse will continue to monitor because the blood pressure of 168/101 mmHg does not meet the threshold to notify the PCP. A blood pressure of 150/100 mm Hg is needed to maintain cerebral perfusion after an acute ischemic stroke.

The nurse is caring for a client who sustained an ischemic cerebrovascular accident (CVA) three hours ago. The client's most recent blood pressure was 168/101 mm Hg. The nurse should take which action? A. Place the client supine B. Continue to monitor C. Obtain orthostatic blood pressure D. Request a prescription for an antihypertensive

Choice B is correct. Safety should be the highest priority for the client. Clients with Alzheimer's disease are unaware of their surroundings and tend to wander. The nurse should implement safety measures.

The nurse is caring for a client with Alzheimer's disease. Which nursing problem would be the nurse's primary concern? A. Inability to do activities of daily living. B. Increased risk for injury. C. Potential for constipation. D. Ineffective family coping.

Choices B, C, and E are correct. The cardinal features of Huntington's disease include neurological symptoms such as chorea (brief, involuntary movements involving the trunk, limbs, and face) and cognitive dysfunction (memory loss, poor judgment). This disease also has common psychiatric symptoms such as depression, paranoia, delusions, and hallucinations. Weight loss is also a common finding caused by the excessive energy expended in abnormal movements.

The nurse is caring for a client with Huntington's disease. Which of the following assessment findings would be expected? Select all that apply. Halitosis Chorea Hallucinations Hematemesis Weight loss

Choices A, B, C, and F are correct. An array of symptoms may be reported for a client experiencing a migraine headache (MH). The most common manifestations associated with an acute migraine headache include Unilateral frontotemporal pain that may be described as throbbing or dull Sensitivity to light (photophobia) and sound (phonophobia) Nausea and/or vomiting Altered mentation (drowsiness) Dizziness, numbness, and tingling sensations

The nurse is caring for a client with a migraine headache. Which assessment findings should the nurse expect? Select all that apply. unilateral frontotemporal pain drowsiness phonophobia shuffling gait dysphagia Vomiting

Choices A, B, C, and F are correct. An array of symptoms may be reported for a client experiencing a migraine headache (MH). The most common manifestations associated with an acute migraine headache include Unilateral frontotemporal pain that may be described as throbbing or dull Sensitivity to light (photophobia) and sound (phonophobia) Nausea and/or vomiting Altered mentation (drowsiness) Dizziness, numbness, and tingling sensations

The nurse is caring for a client with a migraine headache. Which assessment findings should the nurse expect? Select all that apply. unilateral frontotemporal pain nausea photophobia fever nuchal rigidity Vomiting

Choice A is correct. Absent bowel sounds, gastric distention, bradycardia, hypotension, and flaccid paralysis are concerning findings for spinal shock. When caring for a client following a spinal cord injury, spinal shock is one of the many complications which may occur within 48 hours following the injury.

The nurse is caring for a client with an acute spinal cord injury. Which client finding would require immediate follow-up? A. absent bowel sounds B. blood pressure 134/82 mm Hg C. pulse 92/minute D. hyperreflexia

Choice B is correct. Since Meniere's disease causes vertigo or the feeling that one is spinning, the patient is at an increased risk for falls. To keep this patient safe, the nurse must initiate fall risk measures.

The nurse is caring for a patient with Meniere's disease. Which of the following nursing interventions is of the highest priority when caring for this patient? A. Discussing treatment options B. Initiating fall risk measures C. Keeping the patient calm during an episode D. Providing teaching on potential causes

Choice A is correct. Drug-induced delirium, from prescription or OTC medications, is more common in the elderly due to slower metabolism and absorption. Polypharmacy (concomitant use of multiple medications) is a very common cause of delirium in older adults. Combinations of digoxin, diuretics, analgesics, and anticholinergics should be examined. Assessing the client's current medication list, including any recent changes or additions, is crucial to determine if drug intoxication is contributing to the delirium.

The nurse is caring for an elderly home health client experiencing a sudden onset of delirium. Which of the following should the home health nurse assess first? A. Drug intoxication B. Increased hearing loss C. Cancer metastases D. Congestive heart failure

Choices A, B, E, and F are correct. An acute illness (fever, sepsis, infection) typically causes delirium, so delirium often has an abrupt onset (choice A) with rapid progression. Significant changes in psychomotor activity result in hyperactivity or hypoactivity (choice B). Delirium is typically reversible when the underlying illness is resolved. Delirium typically lasts for hours to days, whereas dementia is a chronic condition that worsens over time. A disturbance in attention and awareness characterizes delirium (Choice E), while in dementia, these functions are usually intact until the later stages of the disease. A fluctuating level of consciousness (Choice F) is a hallmark symptom of delirium.

The nurse is caring for an older adult brought to the emergency department with concerns about delirium. Which of the following findings would support a diagnosis of delirium? Select all that apply. Abrupt onset Change in psychomotor activity Irreversible Progressively worsens Decreased attention and awareness Fluctuating level of consciousness

Choice B is correct. When transferring a patient with paralysis of the lower extremities from a bed to a wheelchair, move the big part of the body (upper) to the chair first. This is the proper technique and the safest. The client should move his upper body to the wheelchair first, then his legs from the bed to the wheelchair.

The nurse is conducting patient teaching to a client with a level T4 spinal cord injury to transfer from the bed to the wheelchair independently. The nurse should emphasize to the client to move: A. His upper and lower body should move together into the wheelchair. B. His upper body moves into the wheelchair first. C. His lower body into the wheelchair first, placing his feet on the pedals, and then his hands to the wheelchair arms. D. His buttocks to the wheelchair first and then place his feet to the floor.

Choices A, B, C, E, and F are correct. Advanced Alzheimer's disease requires the nurse to utilize skill and patience. This progressive neurodegenerative disorder causes memory impairments but then erodes executive functioning, which may lead to indecisiveness, behavioral disturbances, impulsivity, and emotional lability. Assessing the client for falls is universal and should occur for a client with AD, especially with advancing AD, because of the client's inability to make sound judgments. Hyperorality is when the client puts everything in the mouth to taste and chew. As executive functioning declines, this may manifest and present a choking hazard. The nurse should ensure objects such as batteries, safety pins, buttons, etc., are not within the client's immediate environment. Consistent caregivers are always a good option (AD or not). Consistent caregivers decrease anxiety because it allows rapport building and promotes a sense of trust. This familiarity may reduce the emotional lability associated with anxiety for the client with AD. A low-stimulation environment is helpful for the client with AD. Flashing lights and loud noises may create a sense of anxiety which can make the client r

The nurse is developing a plan of care for a client with advanced Alzheimer's disease. Which of the following should the nurse include? Select all that apply. Assess the client's risk for falls Monitor the client for hyperorality Provide consistent caregivers Obtain a prescription for as-needed (PRN) diphenhydramine Foster a low-stimulation environment Offer limited choices

Choices A and B are correct. The hypoglossal cranial nerve (XII) is central to the skeletal muscles of the tongue and assists with swallowing. If a client has an impairment of this cranial nerve, aspiration precautions should be implemented. These precautions include observing the client during meals and having patent suction at the bedside.

The nurse is developing a plan of care for a client with an impairment to the hypoglossal cranial nerve. Which of the following should the nurse include in the client's plan of care? Select all that apply. Observe the client during meals Keep suction at the bedside Provide large print education materials Teach the client to scan the room Alternate the use of an eye patch

Choice D is correct. Referring the client to a home health agency can be a suitable choice as it encompasses a broader spectrum of care, including physical therapy (PT), occupational therapy (OT), and speech therapy, among others. These services can address the client's rehabilitation needs comprehensively, including both speech and balance deficits. It provides a holistic approach to the client's physical and functional recovery, making it a valid and convenient choice for ongoing care and rehabilitation.

The nurse is discharging a client that has been admitted due to subarachnoid hemorrhage. The client still has some speech and balance deficits. Which referral would the nurse expect for this client? A. Refer the client to hospice care. B. Refer the client to speech therapy. C. Refer the client to physical therapy. D. Refer the client to a home health agency.

Choice B is correct. Circadian rhythm is the 24-hour internal clock in our brain that regulates cycles of alertness and sleepiness by responding to light changes in our environment. This internally driven rhythm resets every day by the sun's light/dark cycle. The internal body clock sets the timing for many circadian rhythms, which regulate sleep-wake cycles, eating, digestion, body temperature rhythm, hormonal activity, and other bodily functions.

The nurse is discussing biological clocks with another nurse. What term is used to describe a human's innate biological clock relating to daytime and nighttime wakefulness and activity? A. REM sleep B. Circadian rhythm C. Diurnal rhythm D. Nocturnal activity

Choice D is correct. To test peripheral responses to pain, health care providers should apply pressure to outer body parts such as the toes or fingers. Pressing on the patient's nail bed is the most appropriate action.

The nurse is evaluating a patient's response to peripheral pain. Which technique should the nurse use to perform this evaluation? A. Pressure on the patient's mid-back B. Sternal rub C. Squeezing the sternocleidomastoid muscle D. Pressing on the patient's nail bed

Choice A is correct. A C6-C7 spinal cord injury (SCI) can still retain some ability to extend shoulder, arms, and fingers with compromised dexterity in the hands and fingers. The client showing that she can maneuver a wheelchair indicates that she has progressed in therapy. Rehabilitation often will focus on learning to use the non-paralyzed portions of the body to regain varying levels of autonomy. Upon successful treatment, survivors of injuries at the C6/C7 level may be able to drive a modified car with hand controls. The C6 and C7 cervical vertebrae (and the C8 spinal nerve) form the lowest levels of the cervical spine and directly impact the arm and hand muscles. The C6/C7 injury has the potential to change everything below the top of the ribcage, resulting in quadriplegia or paraplegia. Physical therapy is an essential part of recovery. The patient will need to maintain any function not lost by the cord damage, as well as try to regain function. In acute rehabilitation of C6/C7 SCI patients, the focus is on strengthening the upper extremities to the maximal level in patients with complete paraplegia. Empowering exercises for shoulder rotation are proposed for using crutches, swimmi

The nurse is evaluating the progress of a completely paraplegic female client with a C6-C7 spinal cord injury. Which indicator signifies that the client is improving in physical therapy? A. The client can control the motorized wheelchair. B. The client states she wants to stand up with assistance. C. The client says she wants to move her toes. D. The client says she regained her bladder control.

Choice A is correct. Atonic seizures are drop attacks or drop seizures that cause a sudden loss of muscle tone and result in the client collapsing. This is quite serious as this may cause a client to sustain an injury.

The nurse is observing a client with epilepsy have a sudden loss of muscle tone that lasts for a few seconds. The nurse is correct in identifying this as which of the following? A. Atonic seizure B. Tonic-clonic seizure C. Absence seizure D. Complex partial seizure

Choice B is correct. Clonus is an abnormal response to deep tendon reflex stimulation characterized by rapid, rhythmic muscle contractions.

The nurse is performing a physical assessment on a client. Which of the following findings would indicate a positive result for clonus? A. Rubor of the feet and ankles when the leg is in the dependent positon B. Rapid, rhythmic muscle contractions C. Popping or clicking of the knee joint with movement D. Audible cracking and palpable grating with movement of the joints

Affect was flat, and the client appeared withdrawn They demonstrated their cane use by placing the cane in their left hand. removed the rubber tip on the cane missing one physical therapy and one medical appointment

The nurse is performing an initial home health visit recovering from a stroke with left-sided weakness. Initial visit completed. The client was alert and fully oriented. Affect was flat, and the client appeared withdrawn During the visit, the client reported full adherence to their prescribed medications. They demonstrated their cane use by placing the cane in their left hand. The client also reported that they removed the rubber tip on the cane because of its effects on the floors. The client reported missing one physical therapy and one medical appointment because of the lack of transportation.

Choice B is correct. Homonymous hemianopia (HH) is vision loss on the same side of the visual field in both eyes. It is appropriate for the nurse to teach the client to scan the room. Scanning the room will expand the visual field because the same half of each eye is affected.

The nurse is planning care for a client with homonymous hemianopia. The nurse should plan for which intervention in the care plan? A. Place an eye patch over the affected eye B. Instruct the client to turn their head from side to side C. Speak slowly, clearly, and in a deeper voice D. Provide the client with ear plugs to promote rest

Choice D is correct. For clients with acute cerebellar infarction presenting within 4.5 hours of symptom onset, thrombolysis with rtPA is the most appropriate treatment. This medication helps dissolve blood clots and restore blood flow in the affected artery.

The nurse is planning staff education about cerebral infarcts. The nurse knows which of the following options is the most appropriate treatment for clients with acute cerebellar infarction presenting within 4.5 hours of symptom onset? A. Thrombectomy B. Ventriculostomy C. Decompressive sub-occipital craniotomy D. Thrombolysis with recombinant tissue plasminogen activator (rtPA)

Choices C and E are correct. Conductive hearing loss is typically reversible and caused by cerumen, foreign body, tumor, edema, and acute infection. Choices A, B, and D are incorrect. Presbycusis, prolonged exposure to noise, and ototoxic substances cause sensorineural hearing loss. Sensorineural hearing loss is often irreversible.

The nurse is preparing a staff in-service regarding conductive hearing loss. It would be appropriate for the nurse to identify which factors cause this type of hearing loss? Select all that apply. Presbycusis Prolonged exposure to noise Foreign body Ototoxic substance Cerumen

Choices A, B, and D are correct. These are all risk factors for sensorineural hearing loss. Diabetes may cause an insult to vasculature supplying the cochlea. Thus, causing hearing loss. Meniere's disease is a condition that features vertigo, hearing loss, and tinnitus. Exposure to loud noise is a significant risk factor because of the insult it causes to the nerve fibers.

The nurse is preparing a staff in-service regarding sensorineural hearing loss. It would be appropriate for the nurse to identify which factors cause this type of hearing loss? Select all that apply. Diabetes mellitus Menieres disease Excessive cerumen Exposure to loud noise Excessive fluid

Choices B and D are correct. Lowering the side rails and using four-point restraints are inappropriate actions while deploying seizure precautions. Padded bed rails should remain at all times. Clients should be given a call light to call for help if needed. Four-point restraints are inappropriate and unnecessary. This type of restraint is usually reserved for a client engaging in violent behavior.

The nurse is supervising a graduate nurse implement seizure precautions for a client with epilepsy. Which observation by the nurse requires follow-up? Select all that apply. The graduate nurse pads the side rails of the bed lowers the side rails while the client sleeps. removes hard and sharp objects from the bed. places the client in four point restraints to prevent injury. places a fall risk bracelet on the client.

Choice B is correct. Fatigue is a significant clinical feature associated with MS. Strategies to mitigate fatigue and maximize functioning include spacing activities out, planning them in a planner or whiteboard, and taking frequent breaks. Fatigue is often worsened during elevations in temperature. Thus, activities may be best performed early morning or late evening when temperatures are not as high.

The nurse is teaching a client newly diagnosed with multiple sclerosis. Which of the following statements by the client would indicate a correct understanding of the teaching? A. "If I experience double-vision, I should put an eye patch on both eyes for a few hours." B. "Planning my activities should help manage the fatigue." C. "I should plan to take a hot bath for my muscle spasms." D. "This disease may cause me to have an increased sensitivity to pain."

Choice D is correct. A common symptom often seen in Parkinson's clients is dysphagia resulting from esophageal dysmotility. More specifically, dysphagia places the client at an increased risk of aspiration, especially as the disease progresses. As time progresses, swallowing becomes progressively difficult, and the risk of acquiring aspiration pneumonia increases.

The nurse is teaching a client with Parkinson's disease about dietary considerations. The nurse understands that this client is at highest risk for A. constipation and drooling. B. drooling and a loss of appetite. C. loose stools and choking. D. dysphagia and aspiration.

Choices A, C, and E are correct. Delirium is an alteration in mental status that occurs abruptly. Delirium, unlike dementia, is reversible with treatment. Contributing factors for delirium include fever, hypoglycemia, and infection.

The nurse is teaching a group of students about contributing factors for delirium. The nurse is correct in identifying that delirium can be caused by: Select all that apply. Fever Alzheimer's disease Hypoglycemia Vascular disease Infection

Choice A is correct. This action requires follow-up because, during an acute seizure or status epilepticus, intravenous benzodiazepines such as lorazepam, diazepam, or midazolam should be promptly administered to this client. These medications help terminate the seizure. IV antiepileptics such as valproate, topiramate, and phenytoin should be used secondary only after the acute seizure has terminated. Thus, a medication used to prevent seizure reoccurrence rather than medication used to terminate a seizure is not the priority.

The nurse observes a novice nurse caring for a client experiencing status epilepticus. It will require immediate intervention if the novice nurse does which of the following? A. Prepares to administer intravenous valproate. B. Places the client in a lateral position. C. Activates the rapid response team (RRT). D. Loosens any restrictive clothing.

Choice D is correct. A new onset fixed and dilated pupil following a stroke or a traumatic brain injury indicates acutely increased intracranial pressure (ICP). It may indicate transtentorial cerebral herniation and, if unaddressed, may result in death. This situation warrants immediate medical intervention to decrease the ICP. The nurse needs to notify the physician immediately.

The nurse who is caring for a post-stroke client suddenly notes that the client has a fixed and dilated pupil. What would be the most appropriate action by the nurse? A. Reduce environmental stimuli. B. Reassess after ten minutes. C. Check the client's blood pressure. D. Notify the physician.

neurological assessment findings pulse and temperature

Which of the following assessment findings require immediate follow-up? Select all that apply. neurological assessment findings pulse and temperature gastrointestinal assessment findings influenza vaccination status daily smoking habit blood pressure and pulse oximetry reading

neurological assessment current medications reports of dizziness\ reports of nausea

Which of the following assessment findings require immediate follow-up? Select all that apply. pulse, respirations, and blood pressure neurological assessment temperature and pulse oximetry reading current medications reports of dizziness lung sounds reports of nausea arm pain

Choice D is correct. The optic nerve is the second cranial nerve (CN II) responsible for transmitting visual information. Compromise of the CN II results in visual field defects and/or visual loss. As a result, the client's vision will be impaired, and fall risk will increase. "The client will remain free of falls while hospitalized" is an appropriate outcome statement for a newly hospitalized client experiencing a CN II impairment, as the client's current visual impairment places the client at high risk of falls, the client's safety is a priority under Maslow's hierarchy of needs, and this nursing diagnosis includes a clear, measurable outcome.

Which of the following outcome statements would be most appropriate for a newly hospitalized client experiencing an impairment of the second cranial nerve (CN II)? A. The client will not experience sensory overload in the hospital. B. The client will list ways to effectively decrease their blood pressure. C. The client will participate in physical therapy to improve balance. D. The client will remain free of falls while hospitalized.

Choices B and D are correct. Prednisone or another corticosteroid is likely to be prescribed. The anti-inflammatory action of these medications may help to reduce the swelling of the facial nerve and lessen the impingement that is causing the facial drooping. Antivirals are controversial, but some studies show that the combination of antivirals with corticosteroids may be helpful in clients with severe facial drooping. Both of these medications should be given as soon as possible after the symptoms start. Physical therapy to massage facial muscles can help to minimize permanent damage.

You are working in a Family Practice office. A client comes into the office with right facial drooping. The physician makes a diagnosis of Bell's palsy. You know that the primary treatment for this disease is likely to include: Select all that apply. Surgery Prednisone Antibiotic Antivirals Enoxaparin

Choices A, B, C, and D are correct. A is correct. Confusion is common in older adults with a change in mental status, including those admitted to the hospital for pneumonia. It can be an early indicator of underlying conditions and requires further assessment and intervention. B is correct. Disorientation refers to confusion about time, place, or personal identity. It can indicate an altered mental state and may be observed in older adults with pneumonia or other medical conditions. C is correct. Agitation, characterized by restlessness, irritability, or emotional distress, can indicate an altered mental state in older adults with pneumonia. It may suggest discomfort, underlying infection, or other contributing factors. D is correct. Delirium is an acute and fluctuating change in mental status characterized by confusion, disorientation, and impaired attention. Multiple factors, including infections, medication side effects, or metabolic imbalances, can cause it.

The nurse is caring for an 82-year-old male client admitted to the hospital for pneumonia. Which of the following findings may indicate a change in mental status? Select all that apply. Confusion Disorientation Agitation Delirium Hypervigilance

Choice B is correct. Reducing dietary sodium intake is key to reducing attacks associated with Meniere's disease. By reducing sodium, the client will reduce endolymphatic fluid, reducing the incidence of attacks.

The nurse is preparing to teach a client who was recently diagnosed with Meniere's disease. To help the client reduce the incidence of attacks, the nurse should recommend that the client do which of the following? A. Irrigate their ear with sterile water. B. Reduce dietary sodium intake. C. Not use earbuds or headphones. D. Speak with limited inflections.

Choice A is correct. This image shows the plantar reflex, also known as the Babinski reflex. The plantar reflex occurs after the sole has been stroked upwards. It causes the big toe to move upward, and the other toes fan out.

The nurse is supervising a student nurse caring for a newborn. Which of the following reflexes, if elicited by the student nurse, would be the plantar reflex?

Choice C is correct. Agnosia is a clinical feature associated with dementia. Agnosia is the inability to identify familiar objects or people, even a spouse.

The nurse observes a client with dementia not recognizing their family member. The nurse understands that this client is demonstrating signs of which of the following? A. Apraxia B. Agraphia C. Agnosia D. Aphasia

Choice B is correct. Most seizures last from 30 seconds to two minutes. The nurse should time the seizure and ensure it resolves because if the seizure lasts for more than 5 minutes or occurs repetitively without the person regaining consciousness between the seizures, it is defined as "status epilepticus." Status epilepticus is a medical emergency.

The nurse observes the client having a tonic-clonic seizure. Which appropriate action should the nurse take? A. Call a code blue B. Note the time of when the seizure started C. Step out of the room to quickly bring pads for the side rails D. Elevate the client's head-of-bed

removal of the client's clothing; the insertion of an indwelling urinary catheter

The nurse should delegate to the UAP ____ The nurse should delegate to the LPN ____

Vital Signs BP 98/60 T 105° F (40.5° C) P 110 beats per minute RR 25 breaths per minute Cardiovascular Thready peripheral pulses Respiratory Tachypnea Shallow respirations Neurological Lethargic Confused

Vital Signs BP 98/60 T 105° F (40.5° C) P 110 beats per minute RR 25 breaths per minute Oxygen saturation 95% Cardiovascular All pulses palpable Thready peripheral pulses Respiratory Clear lung fields Tachypnea Shallow respirations Neurological Lethargic Confused

Choice C is correct. Alzheimer's disease is the most common degenerative neurological illness and the most common cause of cognitive impairment. It is irreversible, progressing from deficits in memory and thinking skills to an inability to perform even the simplest of tasks.

What is the leading cause of cognitive impairment in old age? A. Stroke B. Malnutrition C. Alzheimer's disease D. Loss of cardiac reserve

Choice D is correct. The perception of pain and its impact on clients greatly varies among individuals. For example, age, gender, genetics, cultural beliefs, and individuals' unique pain thresholds all impact clients' perceptions of pain and pain response.

Which statement below relating to pain and pain perception is accurate? A. Allodynia is the pathophysiological absence of pain when a painful stimulus is applied. B. Scientific evidence does not support the presence of pain during neonatal circumcision. C. Hyperalgesia is the opposite of hyperpathia, both of which are abnormal pain responses. D. The perception of pain and its impact on clients vary greatly among individuals.

- Generalized shivering - No urine output in the past two hours

Which two (2) findings in the nurses' note would require immediate follow-up? Rectal temperature of 103° F (39.4° C) Generalized shivering No urine output in the past two hours Peripheral pulses still thready Client reports of thirst

General assessment and stabilization Neurologic assessment by the stroke team Obtain a non-contrast CT scan Administer rtPA

You are working in the emergency department when a patient with a suspected stroke arrives. According to the American Heart Association (AHA), all of the tasks listed below should be done for this patient. What is the correct sequence for these tasks? Obtain a non-contrast CT scan Neurologic assessment by the stroke team Administer rtPA General assessment and stabilization

Choice B is correct. This picture represents a clinical assessment symptom called Raccoon's eyes (retroorbital ecchymosis). Pooling of blood surrounding the eyesis most often associated with fractures of the anterior cranial fossa or basilar skull fracture. This assessment finding may be delayed by 1 to 3 days following the initial injury. If bilateral, this sign is highly suggestive of a basilar skull fracture. Other signs of basilar skull fractures include hemotympanum (pooling of blood behind the tympanic membrane) and Battle sign (retro auricular or mastoid ecchymosis).

A 24-year old woman presents to the emergency department and appears as shown in the exhibit. What type of injury does this assessment finding suggest? See the exhibit. View Exhibit A. CSF leak B. Basilar skull fracture C. Brown-sequard syndrome D. Subarachnoid hemorrhage

Choice B is correct. This is the best answer based on the patient's symptoms of weakness on one side but sensory loss (pain sensation loss) on the other. The Brown-Sequard syndrome is an incomplete spinal cord injury characterized as a weakness/paralysis (hemi-paraplegia) on the ipsilateral (same) side of the body and sensory loss (hemianesthesia) on the contralateral (opposite) side of the body below the level of injury. It is also known as the hemi-section of the spinal cord. At the level of the injury, there is a complete loss of sensation and flaccid paralysis. Below the level of the injury, there is spastic paralysis and the Babinski reflex (extensor plantar response) on the ipsilateral side. Brown-Sequard Syndrome may be due to traumatic or non-traumatic injuries. However, traumatic injuries such as gunshot wounds, stab wounds, motor vehicle accidents, or blunt trauma are more common causes than non-traumatic etiologies.

A 28-year-old woman presents to the trauma bay after being shot in the upper back. She can move the left side of her body but cannot move the right. However, she cannot feel any pain in the left. The nurse knows these symptoms suggest which type of spinal cord injury? A. Incomplete spinal cord injury, central cord syndrome B. Incomplete spinal cord injury, Brown-Sequard syndrome C. Complete spinal cord injury, paraplegia D. Incomplete spinal cord injury, anterior cord syndrome

Choice D is correct. Halo's sign is an indication of a basilar skull fracture. Rhinorrhea can occur from a basilar skull fracture. When this finding is assessed, the provider can place a drop from the nose onto a piece of gauze. The CSF will form a ring around the outside of the drop. This is referred to as Halo or double-ring sign.

A 30-year-old man was involved in a head-on collision and was unconscious for two minutes prior to EMS arrival. Five minutes before arriving to the hospital, the paramedic notices clear fluid draining from the patient's nose. Having seen this before, the paramedic places a drop from the patient's nose onto a piece of gauze. The nurse is looking for a clinical finding that is called the halo's sign. What type of fracture does the paramedic suspect the patient has? A. Depressed skull fracture B. Traumatic linear skull fracture C. Subarachnoid hemorrhage D. Basilar skull fracture

Choice B is correct. Clients taking magnesium sulfate are expected to become sleepy during the daytime as well as experience hot flashes and lethargy.

A client admitted to the medical ward for convulsions is receiving intravenous magnesium sulfate. Which of the following signs indicate an expected side effect of the drug? A. Less frequency of urination B. Frequent sleepiness C. Absence of a knee jerk reflex D. Decreased respirations

Choice D is correct. Following the alarm indicating a drop in the client's blood pressure, the nurse's initial action should be to assess the client first and, based on the nurse's findings, provide appropriate interventions to address the client's situation. Based on Maslow's hierarchy of needs, this alarm indicates a potential issue with one of the client's physiological needs, which requires immediate assessment and possible intervention. Once the client's needs have been addressed, other tasks (including tasks related to bedside clinical hand-off and report) can be performed.

A client is in the intensive care unit, admitted with a subdural hematoma. Just before shift change, as the nurse prepares to provide a bedside clinical hand-off and report, an alarm goes off, indicating a drop in the client's blood pressure. The initial action of the nurse would be: A. Turn the alarm off and inform the oncoming nurse of the drop in the client's blood pressure. B. Lower the blood pressure alarm limits on the monitor to allow for an uninterrupted bedside clinical hand-off and report. C. Perform the bedside clinical hand-off and report, including information regarding the client's blood pressure drop. D. Assess the client and intervene as needed.

Choice C is correct. The client is displaying acute confusion. The best response for the nurse would be to provide the client with additional food as he requests it.

A client with Alzheimer's disease is eating in the dining hall along with the other clients. Thirty minutes later, he says to the nurse, "When can I have my breakfast? They haven't given me anything to eat yet." The most appropriate response for the nurse would be: A. "I saw you eating breakfast 30 minutes ago." B. "Are you still not full? I'll ask the kitchen what they served you." C. "I can get you some bread if you like. What else would you like?" D. "You have to wait until it's lunchtime."

Choice A is correct. A lumbar puncture (LP) reduces a client's cerebrospinal fluid volume and pressure. As a result of this decreased volume and pressure, headache results. This post-lumbar puncture headache is a common post-procedure complication, usually occurring hours to one to two days following the procedure, with severity ranging from moderate to severe. Hydration is a primary treatment for post-lumbar puncture headache. Increasing the client's fluid intake would facilitate the restoration of the client's cerebrospinal fluid volume.

A lumbar puncture was performed on a client for a myelogram. After the procedure, the client complains of a severe headache. The most appropriate nursing intervention is: A. Increase the client's oral fluid intake B. Administer the prescribed antihypertensives to the client C. Give the client roll lenses D. Place a cool pack over the lumbar puncture site

Choice C is correct. Seizures pose a significant risk of injury, and implementing seizure precautions helps to create a safe environment for the client during a seizure episode. Side rails up and padded as well as the bed in the lowest position prevent the client from falling out of bed or injuring themselves on nearby furniture. These precautions can minimize the potential for head injuries, fractures, and other injuries associated with seizures. Other precautions might include ensuring that oxygen and suctioning equipment with an airway are readily available. If the client does not have IV access, insert a saline lock, especially if he or she is at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure. Specific seizure precautions vary, depending on health care agency policy.

A nurse is caring for a client with a history of seizures who is at risk for injury. Which intervention is the highest priority to reduce the client's risk of injury? A. Keeping the client's room dimly lit to minimize visual stimulation B. Administer antiepileptic medications as prescribed. C. Implement seizure precautions, including padded side rails up and the bed in the lowest position. D. Provide education to the client and family about seizure triggers and safety measures.

Choice C is correct. The level of injury in the spinal cord correlates with innervation on the skin according to the level of the dermatome.

After a patient experiences a motor vehicle accident (MVA) and suffers a complete spinal cord injury to L3, the nurses would assess for loss of motor function in the: A. Abdomen B. Arms C. Legs D. Chest

communicate the results to the physician surgical intervention andexanet

After reviewing the diagnostic imaging results, the nurse should ____ The nurse should prepare the client for possible ____ To reverse the anticoagulant effects, the nurse should obtain a prescription for ____

Choice A is correct. In most Parkinson's disease clients, a resting tremor of one hand is often the first symptom. The classic sign associated with Parkinson's disease is the "pill-rolling" nature of the hand tremors. More specifically, this involves the wrist and fingers, or, alternatively, the thumb moving against the index finger (pill-rolling), as when an individual rolls a pill in their hand or handles a small object. Treatment is considered valid when these tremors are lessened.

Following a recent diagnosis of Parkinson's disease, a client was prescribed carbidopa/levodopa. At the follow-up appointment, which of the following objective assessment findings would indicate the effectiveness of the medication? A. The tremors have lessened in frequency B. The frequent swallowing has stopped C. The seizures have spaced out D. There is decreased lacrimation

Choices B, C, D, and E are correct. All of these answer choices are symptoms of autonomic dysreflexia. Autonomic dysreflexia (AD) is a life-threatening condition in which the involuntary nervous system overreacts to external stimuli. AD is commonly seen in people with spinal cord injuries above the sixth thoracic vertebra, or T6. It may also affect people with multiple sclerosis, Guillain-Barre Syndrome, and certain head or brain injuries. AD can also be a side effect of medication or drug use. In individuals with spinal cord injury at or above the T6 level, there is a loss of normal autonomic nervous system control, leading to a lack of sympathetic regulation of the sweat glands. As a result, when a noxious stimulus or irritation (such as bladder distension) occurs below the level of injury, it can trigger a reflex sympathetic response, leading to sweating above the level of injury. Autonomic dysreflexia causes: A dangerous spike in blood pressure (systolic readings often over 200 mm Hg) Pounding headache (choice B) Flushing of the skin above the level of spinal cord injury (choice C) Nasal congestion (choice D) Profuse sweating above the level of injury, particularly over the forehead

In a client with spinal cord injury, the nurse understands which of the following symptoms are indicative of autonomic dysreflexia? Select all that apply. Hypotension Sudden headache Flushed face Nasal congestion Profuse sweating above the level of the injury

Glasgow coma scale

It is essential for the nurse to prioritize a ____ assessment before transferring the client to the intensive care unit.

Choice D is correct. Minimizing and challenging the client's report of pain/pain intensity is in violation of the American Nurses Association's standards of care about pain/pain management. Specifically, the American Nurses Association's Standards of Professional Performance for Pain Management Nursing. For example, nurses are mandated to document pain as expressed by the client regardless of what the nurse believes to be true and accurate.

Minimizing and challenging the client's report of pain and pain intensity is: A. Often necessary if the client has a history of substance abuse. B. Often necessary if the client has a history of drug seeking behavior. C. Contrary to and in violation of the Nightingale oath. D. Contrary to and in violation of the American Nurses Association's standard of care.

Choice C is correct. Based on the symptoms provided and the timing of the medication administration, the client is suffering from an opioid overdose following the administration of intravenous morphine. The most appropriate nursing action is administering naloxone, an opioid antagonist that rapidly reverses opioid overdoses by attaching to opioid receptors, reversing and blocking the effects of opioids in the client's system.

Minutes after administering an intravenous dose of 10 mg of morphine, the nurse notes that the client's blood pressure has dropped from 122/83 mmHg to 88/67 mmHg, and the client's respirations are now 8/minute. Which nursing action is the most appropriate? A. Prepare for intubation B. Prepare to administer a dopamine infusion C. Administer naloxone D. Start an intravenous infusion of normal saline

Choice B is correct. "At risk for abnormal and irreversible pain related to hyperalgesia" is an appropriate nursing diagnosis for a client who is affected with hyperalgesia. Hyperalgesia, which is synonymous with hyperpathia, is abnormal pain processing that can lead to the appearance of neuropathic pain that is irreversible if left untreated.

Select an appropriate nursing diagnosis for your client who is affected with hyperalgesia. A. At risk for inadvertent narcotic overdoses related to hyperalgesia. B. At risk for abnormal and irreversible pain related to hyperalgesia. C. At risk for somatic pain related to hyperalgesia. D. At risk for visceral pain related to hyperalgesia.