eye and vision disorders 3
A nurse is caring for a client following a complete spinal cord transection injury. The client's family asks the nurse what the term paraplegia means. Which of the following responses should the nurse make?
"He is unable move his lower body and legs."
A nurse is reinforcing teaching with a client who is scheduled for a CT scan of the head with contrast. Which of the following statements by the client should the nurse identify as understanding of the teaching?
"I can take medication up to 2 hr before the procedure."
A nurse caring for a client who is recovering from a stroke. The client states "I feel like less of a man. My wife says she is thankful I am alive but I'm sure this is not how she expected us to spend our retirement years." Which of the following is an appropriate response?
"In what ways do you feel like you are less of a man?"
A nurse is caring for a client who has hemiplegia following a stroke. The client's adult son is distressed over his mother's crying and condition. Which of the following responses should the nurse make?
"It must be hard to see your mother so ill and upset."
A nurse is caring for the client who has Ménière's disease. When asked by the client if he is allowed to ambulate independently, which of the following responses should the nurse make?
"Please call for assistance when you wish to get out of bed." MY ANSWER
A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease. The client becomes agitated and combative when the nurse approaches him. Which of the following actions should the nurse plan to take
Calmly ask the client if he would like to listen to some music. MY ANSWER
A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan?
Change the nasal drip pad as needed. MY ANSWER
A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to take hydroxyzine preoperatively. Which of the following effects of the medication should the nurse include in the teaching? (Select all that apply.)
Decreasing anxiety Controlling emesis Reducing the amount of narcotics needed for pain relief
A nurse is contributing to the plan of care for a client who is having headaches following the administration of a spinal anesthetic during surgery. Which of the following interventions should the nurse include in the plan of care?
Encourage increased intake of fluids. MY ANSWER
A nurse is reinforcing teaching with the family of a client who has primary dementia. Which of the following manifestations of dementia should the nurse include in the teaching?
Forgetfulness gradually progressing to disorientation
A nurse is planning care for a client who is postoperative. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)
Have the client sit at the bedside prior to getting up is correct. S Provide pain medications around the clock for the first 48 hr.
A nurse is reviewing HIPAA with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further instruction?
Information about a client can be disclosed to family members at any time
A nurse is caring for a client who is scheduled for a Tensilon challenge test to check for myasthenia gravis. Which of the following findings should the nurse identify as a positive result?
Muscle strength becomes temporarily stronger. MY ANSWER
A nurse is collecting data from an adult client who has meningococcal meningitis. Which of the following findings should the nurse expect?
Petechial rash on the chest and extremities MY ANSWER
A nurse is caring for a client who has a spinal cord injury. The nurse suspects that the client has autonomic dysreflexia. Which of the following actions should the nurse take first?
Raise the head of the bed.
A nurse is caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?
Remind that the client look for food on the left side of the tray.
A nurse is reviewing discharge instructions with the family of a client who sustained a minor head injury earlier in the day. Which of the following instructions should the nurse include?
Repeatedly ask the client questions to check for orientation.
A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?
Suction saliva from the client's mouth. MY ANSWER
A nurse is reinforcing teaching with the family of a client who is in a halo fixation device. Which of the following statements should the nurse make?
The purpose of this device is to immobilize the cervical spine."
A nurse is caring for a client who has global aphasia. Which of the following actions should the nurse take?
Use the exact same words when repeating statements.
A nurse is caring for a client who has recently fallen. Complete the following sentence by using the list of options.
drowsiness, pain right shoulder
A nurse collecting data from a client who has Meniere's disease? Which of the following is an expected finding for this client?
gradual hearing loss
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
hearing loss, antibiotics
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to collect data about the client's progress.
obtain an electrocardiogram, provide fluid replacement, potential condition dehydratation, urine output potassium level.
A nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke. Which of the following interventions should the nurse include in the plan?
re establish communication