Evolve Neuro

A client's osteoporosis has progressed dramatically in the last five years, and the client is especially prone to falling. Which statement best reflects the client's understanding of why the risk of falls has increased?

"I have a curvature of my spine, and it is hard to keep my balance."

A client is newly diagnosed with multiple sclerosis. The client is obviously upset with the diagnosis and asks, "Am I going to die?" The nurse's best response is:

"The prognosis is variable; most individuals experience remissions and exacerbations."

A client just has been diagnosed with multiple sclerosis. The client is upset and asks the nurse, "Am I going to die?" What is the nurse's best response?

"There is a variable prognosis, with most individuals experiencing remissions and exacerbations."

A client admitted to the hospital with an acute episode of rheumatoid arthritis (RA) asks why physical therapy has not been prescribed. What is the most appropriate nursing response?

"Your joints are still inflamed and physical therapy can be harmful."

A nurse is planning to transfer a client who is experiencing pain from the bed to a chair. Place the following steps in the order in which they should be implemented.

1.Verify the client's activity prescription. 2.Identify factors that may impact the ability to transfer. 3.Explain the steps of the transfer. 4.Ensure that the wheels on the bed are locked. 5.Position the client in functional body alignment before transferring

The nurse is providing postoperative care for a college student who has undergone a knee arthroscopy for tendon repair. The client is scheduled to be discharged in a few hours and plans to return to the college dormitory and spend the weekend there before returning to class in two days. What is most important for the nurse to include in the client's discharge plans?

Ask the client who is available in the dormitory that could provide assistance.

When a client has gluteal edema, why should the nurse avoid using the gluteus maximus muscle for administration of intramuscular medications?

Blood supply is insufficient for adequate absorption.

A client is admitted to the hospital with a tentative diagnosis of a brain tumor. The nurse recalls that the diagnostic test conducted to confirm this diagnosis is:

Computed tomograph

A client has a decreased serum sodium level. The nurse should assess the client for which signs of hyponatremia? (Select all that apply.)

Confusion Muscle weakness

A client's leg is placed in Buck's extension to immobilize a fracture until surgery can be performed. When caring for this client, the nurse understands that Buck's extension is a type of:

Cutaneous traction

A client with rheumatoid arthritis calls the outpatient clinic to report that pain with exercising has increased. To decrease pain, the nurse should suggest:

Decrease the number of repetitions of the exercises

A nurse is caring for a client who is hospitalized because of injuries sustained in a major automobile collision. As the client is describing the accident to a friend, the client becomes very restless, and his pulse and respirations increase sharply. Which factor probably is related to the client's physical responses?

Delayed psychological response to trauma

The nurse is assisting a client with myasthenia gravis to bathe. The nurse identifies that the client's arms become weaker with sustained movement. What action should the nurse take?

Encourage the client to rest for short periods

A nurse is caring for a client who had a total hip replacement. What nursing action should be incorporated into the plan of care to prevent thrombus formation?

Encouraging the client to perform ankle exercises

A nurse receives a change-of-shift report for a client who had a total hip replacement 24 hours ago. After reviewing the client's clinical record (shown here) and completing a physical assessment, the nurse should conclude that the client is experiencing which complication?

Fat embolism

A client is receiving furosemide (Lasix). For which sign of hypokalemia should the nurse monitor the client?

Flabby muscles

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

How should a nurse assess a client's trigeminal nerve function?

Identifying corneal sensation.

A nurse is caring for a client who just has had surgery on the ear. The nurse should assess for what early indicator of potential damage to the motor branch of the facial nerve?

Inability to wrinkle the forehead

Pyridostigmine (Mestinon) is prescribed for a client with myasthenia gravis. The primary reason that the nurse instructs the client to take pyridostigmine about one hour before meals is to:

Increase chewing strength

To what does the nurse attribute the increased risk of respiratory complications in clients with myasthenia gravis?

Ineffective coughing

A client with chronic osteomyelitis in the leg is scheduled to have a debridement of the infected bone. What should the nurse include in the postoperative plan of care?

Inform the client that the leg may be immobilized in a cast or splint

A client manifests right-sided hemianopsia as a result of a brain attack (CVA). The nurse develops a plan of care and includes:

Instruct the client to scan surroundings

A client has surgery for the creation of burr holes after sustaining head trauma. An early clinical manifestation of meningeal irritation for which the nurse assesses the client is:

Kernig's sign

The nurse is caring for a client who is admitted with a crushing injury to the spinal cord above the level of phrenic nerve origin. What is the result of this type of injury?

Lack of diaphragmatic contractions and respiratory paralysis

A client who had a brain attack (cerebral vascular accident) several months ago is readmitted to the hospital for a complication of immobility. The nurse reviews the client's laboratory test results, obtains vital signs, and performs a physical assessment. Data reveal elevated white blood cells (WBCs), fever of 101.2, and crackles upon auscultation of the bases bilaterally. Based on the results of the client's work-up, which prescribed medication should the nurse consider the priority at this time?

Levofloxacin (Levaquin

To reduce the risk of recurrent painful gout attacks, the nurse teaches the client to avoid which foods? (Select all that apply.)

Liver Shellfish

The nurse is caring for a client two days after the client had a brain attack (CVA). To prevent the development of plantar flexion, the nurse should:

Maintain the feet at right angles to the legs

A client diagnosed with Bell's palsy has many questions about the course of the disorder. The nurse explains that:

Most clients recover from the effects in several weeks

A client is admitted to the hospital with a diagnosis of Parkinson disease. Which common signs of Parkinson disease does the nurse expect to identify when completing a nursing admission history and physical? (Select all that apply.)

Muscle rigidity Blank facial expression

Carbidopa/levodopa (Sinemet) is prescribed for a client with Parkinson disease. Which side effects does the nurse expect? (Select all that apply.)

Nausea Anorexia Mental changes

A nurse is performing the history and physical examination of a client with Parkinson disease. Which assessments identified by the nurse support this diagnosis? (Select all that apply.)

Nonintention tremors Masklike facial expression Low-pitched monotonous voice

A client with multiple sclerosis is informed that this is a chronic, progressive neurological condition. The client asks the nurse, "Will I experience excruciating pain?" What is the nurse's best response?

Pain is not a characteristic symptom of this disease process."

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

The nurse is caring for a client with increased intracranial pressure (ICP). What clinical manifestations are associated with increased ICP? (Select all that apply.)

Psychotic behaviors Jacksonian seizures Nausea and vomiting

A nurse is caring for a client who sustained trauma to the head. What criteria should a nurse evaluate to determine the client's score on the Glasgow Coma Scale (GCS)? (Select all that apply.)

Quality of verbal response Ability to follow commands Stimulus needed to open the eyes

An older client with dementia of the Alzheimer's type is residing in a nursing home. When in bed, the client consistently is found sleeping in the semi-Fowler position. What area of the client's body does the nurse determine is at the greatest risk for developing a pressure ulcer?

Sacrum

A client with a 5-year history of myasthenia gravis is admitted to the hospital because of an exacerbation. When assessing the client, the nurse identifies ptosis, dysarthria, dysphagia, and muscle weakness. The nurse expects what client response?

Strength decreases with repeated muscle use

A client with a history of tuberculosis reports difficulty hearing. Which medication should the nurse consider is related to this response?

Streptomycin

A nurse is precepting an orientee (newly hired nurse). The nurse observes the orientee caring for an unconscious client with increasing intracranial pressure. The nurse should question which intervention that the orientee performs?

Suctioning the oropharynx routinely

A nurse raises three of four of the client's bedside rails at night. Which psychosocial outcome does the nurse hope to achieve through the use of side rails?

Support a sense of security

A client is experiencing diplopia, ptosis, and mild dysphagia. Myasthenia gravis is diagnosed and an anticholinergic medication is prescribed. The nurse is planning care with the client and spouse. What instruction is the priority?

Take the medication according to a specific schedule

Shoulder immobilization is prescribed after surgical repair of a client's rotator cuff. Which criterion should the nurse use to determine that appropriate alignment is achieved by the immobilizer device?

Upper arm lies close to the chest

A client arrives at the nursing unit with neurological deficits after a motor vehicle accident. Using the Glasgow Coma Scale, the nurse assesses what client responses? (Select all that apply.)

Verbal response to speech Eye opening in response to speech Motor activity in response to a verbal command

Carbidopa-levodopa (Sinemet) is prescribed for a client with Parkinson's disease. The nurse monitors the client for which side effects of the medication? (Select all that apply.)

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? Select all that apply.

Vomiting Anorexia Irritability Decreased level of consciousness

A client with rheumatoid arthritis is scheduled to participate in an exercise program that is established at the extended care facility where the client resides. The nurse evaluates that the client understands the purpose of the program when the client states:

"After I eat breakfast, I do one set of exercises slowly, and then I space the rest of them throughout the day.

A client expresses concern about insomnia and asks, "What I can do to get better sleep?" What activities should the nurse recommend? (Select all that apply.)

Follow the same bedtime ritual each night Perform deep-breathing exercises

A client suffered an injury to the leg as a result of a fall. X-ray films indicate an intertrochanteric fracture of the femur. The client will be placed in Buck's traction until surgery is performed. When considering the client's plan of care, the nurse recalls that the primary purpose of Buck's traction is to:

Immobilize the fracture

Which information should be included in the teaching plan for the client who is prescribed sumatriptan (Imitrex) for migraine headache?

Is contraindicated in people with coronary artery disease

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. (Select all that apply.).

Breathing Pulse rate Blood vessel diameter

After becoming incontinent of urine, an older client is admitted to a nursing home. The client's rheumatoid arthritis contributes to severely painful joints. The primary consideration in the care of this client is the need for:

Control of pain

A client has a diagnosis of trigeminal neuralgia. When assessing the client's trigeminal nerve function, the nurse should evaluate:

Corneal sensation

A client is scheduled for a lumbar puncture. What nursing care should be implemented after the procedure?

Maintaining the client in the supine position for several hours

The bed alarm is ringing because of an elderly client attempting to get out of bed. A nurse enters the room and finds the client agitated and confused. The family member is upset and states, "He has never been like this. I don't know what to do." After getting the client back into bed, which of these nursing actions are appropriate?

Request the nursing assistant to stay with the client, while the nurse calls the primary health care provider.

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

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

A client with a head injury is admitted to the hospital. Which client response indicates increasing intracranial pressure?

Widening pulse pressure

After a short hospitalization for an episode of a transient ischemic attack (TIA) related to hypertension, a client is discharged on a regimen that includes chlorothiazide (Diuril). What should the nurse instruct the client to do regarding nutrition? (Select all that apply.)

Eat more citrus fruits Increase intake of dried cooked beans

A client with myasthenia gravis who is taking a cholinesterase inhibitor is admitted to the emergency department in crisis. To distinguish between myasthenic crisis and cholinergic crisis, the nurse expects the health care provider to prescribe:

Edrophonium chloride (Tensilon

What instructions should the nurse provide to a client after a long leg cast is removed?

Elevate the extremity when sitting

A client is to have a computed tomography (CT) scan with contrast to assess a potential brain tumor. The nurse should teach the client what common expected responses to the contrast material? (Select all that apply.)

Flushing of the face Sensation of warmth

The nurse teaches a premenopausal obese client about strategies to prevent osteoporosis. Which strategy identified by the client indicates that the teaching is effective?

Joins a tennis league and practices every day

A nurse is caring for a client who sustained trauma to the head. What criteria should a nurse evaluate to determine the client's score on the Glasgow Coma Scale (GCS)? (Select all that apply.)

Quality of verbal response Ability to follow commands Stimulus needed to open the eyes

A client has a shoulder immobilizer after surgical repair of a fractured humerus. What should be included in the nurse's instruction to the client about the appropriate use of the immobilizer?

Release the wristband to exercise the forearm and hand routinely

A client with a fractured hip is placed in traction until surgery can be performed. What should the nurse explain is the primary purpose of the traction?

Relieve muscle spasm and pain

A client has a history of progressive carotid and cerebral atherosclerosis and experiences transient ischemic attacks (TIAs). The nurse explains to the client that TIAs are:

Temporary episodes of neurological dysfunction

A nursing assistant assigned to provide hygiene to a client who has a history of transient ischemic attacks (TIAs) asks the nurse what a TIA is. What explanation should the nurse provide?

Temporary episodes of neurological dysfunction