ati med-surg neurosensory and musculoskeletal
post-op instructions following cataract surgery - indication client understands?
"I should call my dr if 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.
Parkinson's carvidopa-levodopa - client understands?
"I should expect my urine to be a darker color"
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.
osteoporosis and new rx for alendronate - include in teaching?
"Remain upright for 30 min 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.
teaching a client and fam about dx and tx of alzheimer's - indication the fam understands?
"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.
teaching plan for Meniere's Diseases - instructions to 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.
viral meningitis - which action?
check cap refill at least q 4 hours The nurse should perform a complete vascular assessment at least every 4 hr to monitor for vascular compromise.
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?
Drowsiness is a known adverse effect of carbidopa-levodopa; therefore, clients are taught to avoid heavy machinery and driving if they experience drowsiness.
Planning care for a client following a lumbar puncture.
Ensure the client lies flat for up to 12 hr The client should lie flat for up to 12 hr to prevent cerebrospinal fluid leakage from the puncture site, which can cause a headache.
post op right hip arthroplasty IMAGE
Image 2 - back against back of chair, feet firm on ground
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 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
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
assessing pt who has Rheumatoid arthritis. expected finding
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.
72 post-op AKA & reports phantom limb pain - which action?
admin a dose of gabapentin
ER w myasthenia gravis - increasing muscle weakness & suspected myasthenic crisis - priority?
assist w a Tensilon test
full arm cast pain 8/10 & meds don't relieve - which action?
check the circulation of the affected extremity
balanced suspension skeletal traction and reports intermittent muscle spasms - first action?
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.
basilar skull fracture - following assessment findings should the nurse report to the provider?
clear drainage 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.
pain assessment post-op - findings to determine severity of pain?
client's report of pain on on a pain scale
new dx of osteoarthritis - expected findings? SATA
crepitus w joint mvmt decreased ROM of the affected joint joint pain that resolves w rest 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 is an expected finding with clients who have osteoarthritis because the client's pain limits movement. 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.
quad - throbbing pain and nausea - facial flushing and bp 220/110 - which action first?
elevate the HOB
client w hx of status epilepticus & seizure precautions - which action?
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.
IMAGA - comminuted fracture?
first picture - fracture is several pieces
retinal detachment - expected?
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
right hemispheric stroke - neuro 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.
MS - expected finding?
intention tremors
closed head injury from fall and receiving mech vent - priority?
maintain a PaCO2 of approx 35 mm Hg (prevents hypercarbia and subsequent vasodilation that can lead to increased ICP) 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
client w advancing amyotrophic lateral sclerosis - which intervention is priority?
monitor pulse ox 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.
ER sudden, severe eye pain w blurry vision - primary angle-closure glaucoma - medication?
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.
teaching AP about care for total hip arthroplasty - instructions?
place an abductor pillow between legs when turning the client The nurse should inform the AP that a client who had a total hip arthroplasty should maintain the hip in abduction following surgery to reduce the risk of dislocating the affected hip. The AP should place an abductor pillow between the client's legs when turning the client to keep the hips in abduction.
stroke and right-sided homonymous hemianopsia - to help adapt which action?
remind client to consciously look at both sides of his 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.
head injury following MVA - finding indicates increased ICP?
restlessness
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.
spastic bladder following spinal cord injury - stimulate micturition?
stroke the client's 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
epilepsy and to start phenytoin - which instruction to include in med plan?
take medications at a consistent time 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
ED client suddenly lost consciousness in home and fell - embolic stroke - which med?
tissue plasminogen activator Tissue plasminogen activator is a thrombolytic agent that should dissolve the blood clot that caused the stroke.
RA - expected findings?
ulnar deviation
