AH Unit 5
The client with Guillain- Barre syndrome is scheduled for plasmapheresis and is questioning how this process works. Which of the following statements by the nurse best describes plasmapheresis in the management of this syndrome?
"Antibodies that triggered the autoimmune response are removed from your blood."
You are the nurse caring for a client with Gullian-Barre Syndrome (GBS). The client also and an ascending paralysis. Knowing the potential complication of the disorder, what should you keep ready at the bedside and anticipate the need for?
A suction apparatus and potential need for intubation.
The nurse is caring for a client hospitalized with server exacerbation of myasthenia gravis. When administering medications to this client, what is a priority nursing actions?
Administer medications at exact intervals ordered to prevent symptoms from returning.
The nurse is orientating a new nurse to the neurologic unit. When instructing on the typical care provided to a client with head injuries, which type of medications are frequently administered? Select all that apply.
Anticonvulsant, analgesics.
The client is scheduled for a total left knee arthroplasty in 2 weeks. When would the best time for postoperative nursing management begin?
Before surgery.
When caring for a client who is post-intracranial surgery which of the following is the most important parameter to monitor?
Body temperature
A group of students is studying for a test on traction. The students demonstrate understanding of the types of traction when they identify which of the following as an examples of skin traction?
Buck's
A client who is undergoing skeletal traction complains of pressure on bony areas. Which action would be most appropriate to provide comfort for the client?
Changing the client's position within prescribed limits.
The nurse is caring for a client who was discovering unconscious after falling off a ladder. The client is diagnosed with concussion. All testing is normal. What would be one of the first signs that the patient's intracranial pressure is increasing?
Decreasing level of consciousness
A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?
Elevate the head of the bed.
A nurse would most likely expect the need for open reduction for a client with which of the following?
Fracture where the bone is displaced or the joint is fractured
The nurse is caring for a client with a head injury after a fall from a hayloft. Which of the following indicates the presence of/or leaking of cerebral spinal fluid?
Halo sign
The nurse is caring for a client who continues to have increasingly high intracranial pressure. Which complication is expected unless intracranial pressure is resolved?
Herniation occurs through the foramen magnum.
The nurse is caring for a patient on the neurological unit who is in status epilepticus. What medication does the nurse anticipate being given to halt the seizure?
IV diazepam (Valium)
When describing the sequence of events that occur after a bone breaks, the instructor would identify which of the following as occurring initially?
Muscle flaccidity.
A client's fracture was reduced by surgically exposing the bone and realigning it. The nurse identifies this as which of the following?
Open reduction
The nurse is caring for a client who had an amputation of the left leg above the knee. What position can the nurse place the client in several times per day to promote stump extension and prevent contractures?
Prone
A client you are caring for experiences a seizure, what would be the priority nursing action?
Protect the client from injury.
A nurse is caring for a client experiencing autonomic dysreflexia. Which of the following does the nurse recognize as the source of symptoms?
Sympathetic nervous system
The nurse educates the patient after a total joint replacement on the reason they are wearing intermittent pneumatic compression wraps. Which response is correct?
To prevent a DVT.
When performing pin care, which of the following would be most appropriate?
Use an applicator only once.
A client is recovering from a fractured hip. The nurse would suggest that the client increase intake of which of the following to facilitate calcium absorption from food and supplements?
Vitamin D
The nurse is checking the traction apparatus for a client in skin traction. Which finding would require the nurse to intervene?
Weights hanging and touching the floor.
The nurse is assigned to care for a client who has had a total knee arthroplasty yesterday. What type of pharmacologic therapy does the nurse anticipate administering to this client to prevent complications related to the surgery?
anticoagulation therapy
A client receiving subcutaneous heparin after surgery to repair a fractured hip. The nurse understands that the rationale for this therapy is to reduce the risk for which of the following?
pulmonary embolism
