Evolve - Med Surg - Neuro
A client with cancer is scheduled for a bone scan to determine the presence of metastasis. The nurse evaluates that the teaching before the scheduled bone scan is effective when the client states
"A substance of low radioactivity will be injected into my vein and my body inspected by an instrument to detect where it is deposited."
What should the nurse consider as the goal of therapy when administering allopurinol (Zyloprim) to a client with gout?
Decrease uric acid production
A client who is diagnosed as having a herniated nucleus pulposus complains of pain. The nurse concludes that the pain is caused by the:
Compression of the spinal cord by the extruded nucleus pulposus
A client has a decreased serum sodium level. The nurse should assess the client for which signs of hyponatremia?
Confusion, muscle weaknesses
A client has a diagnosis of trigeminal neuralgia. When assessing the client's trigeminal nerve function, the nurse should evaluate:
Corneal sensation
). What clinical manifestations are associated with increased ICP?
Psychotic behaviors, Jacksonian seizures, nausea and vomiting
A client taking levodopa (L-dopa) is taught about the signs of levodopa toxicity. The nurse instructs the client to contact the primary health care provider if the client develops:
Twitching
A client is admitted with a brain attack (CVA) with left-sided paralysis. The client leans to the left when placed in a sitting position and fails to respond to stimuli in the left visual field. The client's plan of care should include:
Teaching the client to use head movements to scan the left field of vision
asks the nurse what a TIA is. What explanation should the nurse provide?
Temporary episodes of neurological dysfunction
A client returns from surgery after a total hip arthroplasty. A pillow to maintain abduction is in place. Under what conditions should the nurse remove this pillow?
During the client's bed bath
The nurse will prepare the patient for which major side effects of radiation therapy?
Fatigue, Altered taste sensations
A client arrives on the nursing unit unconscious and exhibiting decerebrate posturing. When assessing the client, the nurse expects to observe:
Hyperextension of both the upper and lower extremities
A married couple in their 80s are living independently. They have three adult children. The husband, who is alert but forgetful, has an enlarged prostate and at times is incontinent of urine. The wife has diabetes and rheumatoid arthritis and walks with difficulty. Both need assistance with bathing, dressing, and meal preparation. The nurse suggests the plan that would be the most suitable for this couple is to:
Keep them in their home with a home health aide
The nurse is caring for a client with arthritis. The client asks, "Can I take Tylenol instead of aspirin? Aspirin irritates my stomach." The nurse explains that acetaminophen (Tylenol):
Lacks an anti-inflammatory action
Carbidopa/levodopa (Sinemet) is prescribed for a client with Parkinson disease. Which side effects does the nurse expect?
Nausea, anorexia, mental changes
What should the nurse explain is the primary purpose of the traction?
Relieve muscle spasm and pain
A client with a history of hypertension is admitted to the hospital immediately after a brain attack (CVA). The client is unconscious and the vital signs are temperature 98°F, pulse 78, respiration 16, and blood pressure 120/80. Which nursing concern below is a priority for this client?
Respiratory distress
When providing discharge teaching to a client who had a total hip replacement, the nurse should instruct the client to avoid:
Sitting in a low chair
What should the nurse take into consideration when planning nursing care for a client experiencing an acute episode of rheumatoid arthritis?
Bony ankylosis of a joint is irreversible and causes immobility
a client is discharged on a regimen that includes chlorothiazide (Diuril). What should the nurse instruct the client to do regarding nutrition?
Eat more citrus fruits and Increase intake of dried cooked beans
What instructions should the nurse provide to a client after a long leg cast is removed?
Elevate the extremity when sitting.
A nurse is caring for a client who will have a below-the-knee amputation with an immediate postoperative prosthesis. The client asks the nurse the advantage of having an immediate prosthesis. What should the nurse explain is the advantage?
Encourages a normal walking pattern
The nurse is caring for a client who has sustained blunt trauma to the forearm. The nurse assesses the client for which early sign of compartment syndrome?
Escalating pain in the fingers
A client who is to have a total hip arthroplasty with an uncemented prosthesis asks, "When will I be able to get up and walk?" On what information should the nurse base an answer?
Full weight-bearing may begin the day after surgery.
The nurse is caring for a client who has a tumor of the cerebellum. The client most likely will exhibit:
Inability to execute smooth movements
What does the nurse understand that clients with myasthenia gravis, Guillain-Barré syndrome, and amyotrophic lateral sclerosis (ALS) share in common?
Increased risk for respiratory complications
A client with the diagnosis of multiple sclerosis (MS) develops increased visual problems, progressive muscular weakness, and frequent episodes of emotional lability. The difficulties experienced are very distressing to the client. The client bursts into tears for no apparent reason while having a discussion with the nurse. What is the nurse's best response?
Let the client cry and then resume the discussion
A client is admitted to the hospital with a diagnosis of acute Guillain-Barré syndrome. What frequent assessment does the nurse determine is most important for a client with this syndrome?
Respiratory exchange
A jogger sustains multiple fractures of the femur after being hit by a motor vehicle. A nurse responds to the scene of the accident to assist with care. The nurse recalls that, for this type of fracture, immediate life-threatening systemic complications can be minimized by:
Handling and transporting the client gently
Which statement by a female client with a non-weight-bearing long leg cast indicates the need for the nurse to reinforce discharge teaching?
"I am going to give myself a pedicure with red nail polish when I get home."
A client who has just started on a regimen of haloperidol (Haldol) is observed pacing and shifting weight from one foot to another. What side effect does the nurse document in the client's chart?
Akathisia
Postoperatively, a client complains about a variety of minor environmental factors, frequently changes positions, and avoids eye contact. The nurse responds to these observations by stating, "Let me get you some cold water and your pain pill, and you'll be much better." The nurse's response demonstrates:
An inappropriate interpretation of the assessment findings
A client with rheumatoid arthritis has been given a prescription for acetylsalicylic acid. The client asks the nurse, "What kind of drug is acetylsalicylic acid?" The nurse recalls that the classification to which this drug belongs is:
Analgesics
Which alternative therapy may be beneficial for the nurse to discuss with a client who has terminal bone cancer?
Biofeedback
A client has a diagnosis of myasthenia gravis. The nurse recalls that associated clinical manifestations include
Blurred vision along with episodes of vertigo
A client had a right above-the-knee amputation secondary to trauma sustained in a motor vehicle accident. Six days after surgery, the client falls while attempting to transfer to a chair unassisted. The nurse concludes that this fall is most likely the result of:
Decreased muscle strength
A nurse is caring for a client with glaucoma. What rationale associated with the need for treatment of this condition should the nurse include in a teaching program?
Lost vision cannot be restored
A client has carotid atherosclerotic plaques, and a right carotid endarterectomy is performed. Two hours after surgery the client demonstrates progressive hypotension. The nurse should:
Notify the health care provider [The Trendelenburg position is contraindicated because it will increase pressure in the carotid arteries.]
A client has surgery to repair a fractured right hip. Where should the nurse stand when assisting the client to ambulate?
On the client's left side
The nurse is caring for a client with a distal femoral shaft fracture. For which clinical indicator unique to a fat embolus should the nurse assess the client?
Petechiae
A client has a compound fracture of the femur. The nurse should assess the client for the typical signs and symptoms of a fat embolus. In comparison to thromboembolism, which clinical indicator is unique to a fat embolus?
Pinpoint red spots on the chest
A nurse is caring for a client with a spinal cord injury. Which is the specific reason why fluid intake should be increased for this client?
Prevent a urinary tract infection
A client has rotator cuff surgery. What should be included when the nurse performs a neurovascular assessment of the affected extremity immediately after surgery?
Skin color, movement of hand, sensation in extremity
Carbidopa-levodopa (Sinemet) is prescribed for a client with Parkinson's disease. The nurse monitors the client for which side effects of the medication?
Vomiting, anorexia, changes in mood
The nurse is caring for a client who was just admitted to the hospital with the diagnosis of head trauma. Which clinical indicators should the nurse consider as evidence of increasing intracranial pressure?
Vomiting, irritability, anorexia, decreased LOC
A client returns from the post-anesthesia care unit after a right rotator cuff repair. What should the nurse do when performing a neurovascular assessment?
Assess for capillary refill in the nail beds.
A health care provider recently made the diagnosis that a client has glaucoma. The nurse is preparing to administer eye drops to the client. Which ophthalmic solution is contraindicated for this client?
Atropine
A client newly diagnosed with rheumatoid arthritis is admitted to the hospital with bilateral painful knee and wrist joints. The nurse identifies impaired physical mobility related to painful, swollen joints. What should the nurse teach the client to do during the acute phase of the disease?
Avoid exercises to the involved joints
The nurse teaches a client who developed degenerative joint disease of the vertebral column positioning techniques, including turning from back to side, keeping the spine straight. The nurse explains that the least effort will be exerted if the client crosses the arm over the chest and:
Bends the top knee to the side to which the client is turning
When caring for this client, the nurse understands that Buck's extension is a type of:
Cutaneous traction
A nurse teaches self-care to a client who had a cast applied for a fracture of the right ulna and radius. The nurse instructs the client to notify the primary health care provider immediately if the client experiences
Increasing pain at the injury site
When caring for a client with a head injury that may have involved the medulla, the nurse bases assessments on the knowledge that the medulla controls a variety of functions.
breathing, pulse rate, blood vessel diameter
A client has primary open-angle glaucoma. The nurse expects that the client will receive a prescription for which eye drops?
Timolol maleate (Timoptic)
A client is receiving phenytoin (Dilantin) for a seizure disorder and heparin for a deep vein thrombosis. Warfarin (Coumadin) is added in preparation for discontinuing the heparin. Why must the nurse observe the client closely during the initial days of treatment with warfarin?
Warfarin affects the metabolism of phenytoin.