NCLEX Musculoskeletal & Neurological disorders

A client is treated in the emergency department for acute muscle strain in the left leg caused by trying a new exercise. During discharge preparation, the nurse should provide which instruction? a) "Apply ice packs for the first 24 to 48 hours, then apply heat packs." b) "Apply heat packs for the first 24 to 48 hours." c) "Apply heat packs for the first 24 hours, then apply ice packs for the next 48 hours." d) "Apply ice packs for the first 12 to 18 hours."

"Apply ice packs for the first 24 to 48 hours, then apply heat packs." Explanation: The nurse should instruct the client to apply ice packs to the injured area for the first 24 to 48 hours to reduce swelling and then apply heat to increase comfort, promote reabsorption of blood and fluid, and speed healing. Applying ice for only 12 to 18 hours may not keep swelling from recurring. Applying heat for the first 24 to 48 hours would worsen, not ease, swelling. Applying ice 48 hours after the injury would be less effective because swelling already has occurred by that time.

The nurse is preparing a client for a computed tomography (CT) scan, which requires infusion of radiopaque dye. Which question is important for the nurse to ask?

"Are you allergic to seafood or iodine?"

When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction?

"Avoid hot baths and showers."

A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction?

"Avoid stimulants and alcohol for 24 to 48 hours before the test."

When teaching a client about levodopa and carbidopa (Sinemet) therapy for Parkinson's disease, the nurse should include which instruction?

"Be aware that your urine may appear darker than usual."

When teaching patients who are at risk for Bell's palsy because of previous herpes simplex infection, which information should the nurse include?

"Call the doctor if pain or herpes lesions occur near the ear." rational: Pain or herpes lesions near the ear may indicate the onset of Bell's palsy and rapid corticosteroid treatment may reduce the duration of Bell's palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell's palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell's palsy.

What is the therapeutic level of DILANTIN?

"Dial at Ten" 10-20 = therapeutic level

Which discharge instruction should a nurse give a client who's had surgery to repair a hip fracture? a) "Don't flex your hip more than 60 degrees, don't cross your legs, and have someone help you put your shoes on." b) "Don't flex your hip more than 120 degrees, don't cross your legs, and have someone help you put your shoes on." c) "Don't flex your hip more than 90 degrees, don't cross your legs, and have someone help you put your shoes on." d) "Don't flex your hip more than 30 degrees,

"Don't flex your hip more than 90 degrees, don't cross your legs, and have someone help you put your shoes on." Explanation: Falls in the home cause most injuries among the elderly. Elderly clients should take measures to decrease the clutter that can contribute to falls, such as removing objects such as throw rugs from the floor. Elderly clients should also install grab bars in the shower and next to the toilet. The threat of fire makes burglar bars on every window impractical.

A client undergoes a total hip replacement. Which statement made by the client indicates to the nurse that the client requires further teaching? a) "The occupational therapist is showing me how to use a sock puller to help me get dressed." b) "I'll need to keep several pillows between my legs at night." c) "I need to remember not to cross my legs. It's such a habit." d) "I don't know if I'll be able to get off that low toilet seat at home by myself."

"I don't know if I'll be able to get off that low toilet seat at home by myself." Explanation: The client requires additional teaching if he is concerned about using a low toilet seat. To prevent hip dislocation after a total hip replacement, the client must avoid bending the hips beyond 90 degrees. The nurse should instruct the client to use assistive devices, such as a raised toilet seat, to prevent severe hip flexion. Using an abduction pillow or placing several pillows between the legs reduces the risk of hip dislocation by preventing adduction and internal rotation of the legs. Teaching the client to avoid crossing the legs also reduces the risk of hip dislocation. A sock puller helps a client get dressed without flexing the hips beyond 90 degrees.

A client with Parkinson's disease visits the physician's office for a routine checkup. The nurse notes that the client takes benztropine (Cogentin), 0.5 mg by mouth daily, and asks when the client takes the drug each day. Which response indicates that the client understands when to take benztropine?

"I take the medication at bedtime."

The nurse is teaching a client with trigeminal neuralgia how to minimize pain episodes. Which comments by the client indicate that he understands the instructions?

"I'll try to chew my food on the unaffected side." "Drinking fluids at room temperature should reduce pain.", "If brushing my teeth is too painful, I'll try to rinse my mouth instead."

A client with multiple sclerosis who is unable to bathe herself complains that other staff members haven't been bathing her. How should the nurse respond to this client's complaint?

"I'm sorry you haven't been bathed. I'm available to bathe you now."

A client who was diagnosed with multiple sclerosis 3 years ago now presents with lower extremity weakness and heaviness. During the admission process, the client presents her advance directive, which states that she doesn't want intubation, mechanical ventilation, or tube feedings should her condition deteriorate. How should the nurse respond?

"It's important for us to have this information. You should review the document with your physician at every admission."

A 28-year-old woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate?

"MS symptoms may be worse after the pregnancy." rational: During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Onset of labor is not affected by MS.

A client with idiopathic seizure disorder is being discharged with a prescription for phenytoin (Dilantin). Client teaching about this drug should include which instruction?

"Schedule follow-up visits with your physician for blood tests."

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. What should the nurse tell the client about the paralysis?

"The paralysis caused by this disease is temporary."

A 62-year-old patient is brought to the clinic by a family member who is concerned about the patient's inability to solve common problems. To obtain information about the patient's current mental status, which question should the nurse ask the patient?

"What did you have for breakfast?" rational: This question tests the patient's recent memory, which is decreased early in Alzheimer's disease (AD) or dementia. Asking the patient about birthplace tests for remote memory, which is intact in the early stages. Questions about the patient's emotions and self-image are helpful in assessing emotional status, but they are not as helpful in assessing mental state.

Skeletal Traction

-Applied directly to the bone with pins and wires -Used with prolonged traction is needed

Continuous Passive Motion (CPM)

-Continuously flexes and extends the knee to prevent scar tissue from forming and increasing gradually

Treatment of compartment syndrome

-Elevate extremity (get fluid away) -soft cast then rigid cast -Loosen the cast to restore circulation -Be careful in picking the answer to "remove the cast" -fasciotomy -cast cutters to remove the case (instruct them the cast saw does not touch the skin, but it does vibrate)

Treatment of Fractures

-Immobilize the bone ends plus the adjacent joints -support fracture above and below the site -move extremity as little as possible -splints help prevent fat emboli and muscle spasm

Immediate Post Op care for amputations

-Keep a tournaquette at the bedside -Extension to prevent hip/knee contractions -Inspect the residual limb daily to be sure that it lies completely flat on the bed

Post-Op care for the hip replacement patient

-Neurovascular checks -Monitor drains (don't want fluid to accumulate in tissue) -Firm mattress (joints need support) -Over-bed trapeze to build upper body strength -isometric exercises while in bed -no weight bearing until ordered -hydrate! -stresses to the new hip joint should be minimal in the first 3-6 months -no sleeping on the operative side -do not give pain meds in the operative hip

Should you relieve traction?

-Never relieve traction unless you've got a physician's order

The spouse of a male patient with early stage Alzheimer's disease (AD) tells the nurse, "I am just exhausted from the constant worry. I don't know what to do." Which action is best for the nurse to take next:

-Offer ideas for ways to distract or redirect the patient. -Educate the spouse about the availability of adult day care as a respite. -Ask the spouse what she knows and has considered about dementia care options. rational: The stress of being a caregiver can be managed with a multicomponent approach. This includes respite care, learning ways to manage challenging behaviors, and further assessment of what the spouse may already have considered. The patient is in the early stages and does not need long-term placement. Antianxiety medications may be appropriate but other measures should be tried first.

Infection (after hip surgery)

-Prophylactic antibiotics -remove foley and drains as soon as possible

Phantom Pain

-Seen more with AKA (above knee) -Diversional activity is the first thing to do -Usually subsides in 3 months

Complications with Fractures include:

-Shock (hypovolemic) -Fat embolism -compartment syndrome

When preparing to admit a patient who has been treated for status epilepticus in the emergency department, which equipment should the nurse have available in the room:

-Siderail pads -Oxygen mask -Suction tubing rational: The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk for patient injury during a seizure. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. Use of tongue blades during a seizure is contraindicated.

When caring for a patient who experienced a T1 spinal cord transsection 2 days ago, which collaborative and nursing actions will the nurse include in the plan of care:

-Urinary catheter care -Continuous cardiac monitoring -Avoidance of cool room temperature -Administration of H2 receptor blockers rational: The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. Gastrointestinal (GI) motility is decreased initially and NG suctioning is indicated. To avoid bladder distention, a urinary retention catheter is used during this acute phase. Stress ulcers are a common complication but can be avoided through the use of the H2 receptor blockers such as famotidine.

A patient with Parkinson's disease is admitted to the hospital for treatment of an acute infection. Which nursing interventions will be included in the plan of care:

-Use an elevated toilet seat -Cut patient's food into small pieces -Place an arm chair at the patient's bedside rational: Since the patient with Parkinson's has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High protein foods will decrease the effectiveness of L-dopa. Parkinson's is a steadily progressive disease without acute exacerbations.

More cast care points after the cast is dry

-Watch for breakthrough bleeding (mark the area, circle it, date, and sign site, notice if it is bigger) -cover cast close to groin with plastic once it is dry -neuro-vascular checks with the 5 P's

What do you do if your client complains of pain after the cast is dry?

-assess neurovascular -Most pain is relieved by elevation, cold packs, and analgesics (if these things do not relieve pain, think complication)

Amputations (where are they performed?)

-at the most distal point that will heal -Doc tries to preserve the elbows and knees

Client Education for Rehab after hip surgery

-best exercising is walking -Avoid flexion (low chairs, traveling long distances, sitting more than 30 minutes, lifting heavy objects, excessive bending or twisting, stair climbing)

Avascular Necrosis (after hip surgery)

-death of tissue due to poor circulation

What is the purpose of traction?

-decrease muscle spasms -reduces (realigns) -Immobilizes

Fracture Healing Concerns

-delayed union (healing does not occur at a normal rate) -Non-union (failure of bone ends to unite; may require bone grafting) -Mal-union: deformity at the fraction site

S/S of fat emboli

-depends on where emboli goes petechia or rash over chest conjunctival hemorrhages snow storm on CXR young males first 36 hours of the fracture (after that it is the DVT)

Patho of Compartment Syndrome

-fluid accumulates in the tissue and impairs tissue perfusion -The muscle becomes swollen and hard and the client complains of severe pain that is not relieved with pain meds -Pain is unpredictable -Pain is disproportionate to the injury, if undetected, it may result in nerve damage and possible amputation

Cast Care in first 24 hours after molding

-ice packs on the side for the first 24 hours because the cast is still wet -no indentations -use palms of hands for the first 24 hours when cast is still wet -Keep uncovered and allow for air dry -Do not rest cast on hard surface or sharp edge (use soft pillow, no plastic)

Elevation post amputation

-it is controversial, because of hip contractures -Only elevate for a short time to reduce swelling -Do not elevate on a pillow, elevate the foot of the bed

Positioning for post-op hip replacement

-neutral rotation-toes to the ceiling -limit flexion; want extension of the hip -Abduction -trochanter roll to promote external rotation -Avoid crossing legs and bending over

Things to remember post knee surgery

-never hyper extend or hyperflex the knee -neurovascular checks -pain relief

S/S of fractures

-pain and tenderness -unnatural movement -deformity (possible) -shortening of the extremity (caused by muscle spasm) -crepitus (bones grating together) -swelling -discoloration -worry about compartment syndrome

What type of fractures do you see with fat embolisms?

-pelvic, long bones, crushing injuries

How do you toughen the stump?

-press into a soft pillow -then a firm pillow -then on the bed -then on a chair or wall

Is it ok to massage the stump?

-promotes circulation and decreases tenderness

Common areas for compartment syndrome

-quads -forearms

What is skin traction?

-used short term to relieve muscle spasms and immobilize until surgery -This is when tape or some type of material is stuck to the skin and the weights pull against it. The skin is NOT penetrated

Other Notes to remember about traction

-weights should hang freely -keep patient pulled up in bed and centered with a good alignment -exercise non-immobilized joints -ropes should move freely and knots should be secure/tight -special air filled or foam mattress

A client has an exacerbation of multiple sclerosis accompanied by leg spasticity. The physician prescribes dantrolene sodium (Dantrium), 25 mg by mouth daily. How soon after administration can the nurse expect to see a significant reduction in spasticity?

1 to 2 weeks

What treatment is done for seizure patients?

1) Anticonvulsants: Phebobarbital, Carbamazepine (Tegretol) or Phenytoin (Dilantin). 2) Evaluate consciousness, safety, avoid alcohol. 3) Reduce activities that stimulate and reduce stimuli; no strobe lights because it is repetitive. 4) Reorient client after seizure.

How should you assist with lumbar puncture?

1) Obtain informed consent 2) Have patient empty bladder 3) Explain that she will be injected with a local anesthetic and she may feel pressure during the procedure. 4) Place patient in lateral recumbent position with knees flexed toward abdomen. Help patient to remain in that position. 5) When procedure is over, change to dorsal recumbent and monitor 6) Encourage fluids to reduce headache. 7) You should also label the tubes removed from the body. Discard 1st and 2nd tubes, 3rd tube goes to lab because it does not have any contamination.

What nursing interventions should be implemented for someone with aphasia?

1) Stand in front of client 2) Speak clearly, slowly. 3) Do not shout or speak loudly. They can hear. 4) Be patient and give client time to respond 5) Use nonverbal communication, e.g. touche, smile 6) Assist client with motor aphasia to practice simple words, 7) Listen carefully 8) Provide simple directions 9) Involve family in practice 10) Show picture cards to help convey a message

Complications post-op from hip replacement (4)

1. Dislocation 2. Infection 3. Avascular necrosis 4. Immobility problems

What are the signs and symptoms of Parkinson's Disease?

1. Mask like blank expression 2. pill rolling 3. Shuffling gait 4. propulsive gait 5. tremors 6. bradykinesia 7. loss of ability to swallow 8. decreased blinking 9. muscle rigidity

What are the signs and symptoms of MYASTHENIA GRAVIS?

1. bobblehead 2. ptosis 3. diplopia 4. slow speech 5. frowning 6. decreased tongue movement 7. drooling 8. pupils slowly react 9. increased frowning 10. decreased chewing

What are the signs and symptoms of multiple sclerosis?

1. tinnitus 2. decreased hearing 3. urinary retention 4. spastic bladder 5. constipation 6. nystagmus 7. diplopia 8. blurred vision 9. dysarthria 10. dysphagia 11. numbness 12. tingling 13. weakness 14. paralysis 15. muscle spasticity 16. ataxia 17. vertigo

A client who's receiving phenytoin (Dilantin) to control seizures is admitted to the health care facility for observation. The physician orders measurement of the client's serum phenytoin level. Which serum phenytoin level is therapeutic?

10 to 20 mcg/ml

12. The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which plan to use which of the following to test the client's peripheral response to pain? a. Sternal rub b. Nail bed pressure c. Pressure on the orbital rim d. Squeezing of the sternocleidomastoid muscle

12. Answer B. Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain are tested using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

13. A female client admitted to the hospital with a neurological problem asks the nurse whether magnetic resonance imaging may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the client's history of: a. Hypertension b. Heart failure c. Prosthetic valve replacement d. Chronic obstructive pulmonary disorder

13. Answer C. The client having a magnetic resonance imaging scan has all metallic objects removed because of the magnetic field generated by the device. A careful history is obtained to determine whether any metal objects are inside the client, such as orthopedic hardware, pacemakers, artificial heart valves, aneurysm clips, or intrauterine devices. These may heat up, become dislodged, or malfunction during this procedure. The client may be ineligible if significant risk exists.

14. A male client is having a lumbar puncture performed. The nurse would plan to place the client in which position? a. Side-lying, with a pillow under the hip b. Prone, with a pillow under the abdomen c. Prone, in slight-Trendelenburg's position d. Side-lying, with the legs pulled up and head bent down onto chest.

14. Answer D. The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps open the spaces between the vertebrae.

15. The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid? a. Head mildline b. Head turned to the side c. Neck in neutral position d. Head of bed elevated 30 to 45 degrees

15. Answer B. The head of the client with increased intracranial pressure should be positioned so the head is in a neutral midline position. The nurse should avoid flexing or extending the client's neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down.

17. A male client with a spinal cord injury is prone to experiencing automatic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? a. Strict adherence to a bowel retraining program b. Keeping the linen wrinkle-free under the client c. Preventing unnecessary pressure on the lower limbs d. Limiting bladder catheterization to once every 12 hours

17. Answer D. The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours, and foley catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

18. The nurse is caring for the male client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated? a. Loosening restrictive clothing b. Restraining the client's limbs c. Removing the pillow and raising padded side rails d. Positioning the client to side, if possible, with the head flexed forward

18. Answer B. Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising side rails in the bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible, protects the head from injury, and moves furniture that may injure the client. Other aspects of care are as described for the client who is in bed.

20. The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following? a. Giving the client thin liquids b. Thickening liquids to the consistency of oatmeal c. Placing food on the unaffected side of the mouth d. Allowing plenty of time for chewing and swallowing

20. Answer A. Before the client with dysphagia is started on a diet, the gag and swallow reflexes must have returned. The client is assisted with meals as needed and is given ample time to chew and swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid aspiration.

22. Nurse Kristine is trying to communicate with a client with brain attack (stroke) and aphasia. Which of the following actions by the nurse would be least helpful to the client? a. Speaking to the client at a slower rate b. Allowing plenty of time for the client to respond c. Completing the sentences that the client cannot finish d. Looking directly at the client during attempts at speech

22. Answer C. Clients with aphasia after brain attack (stroke) often fatigue easily and have a short attention span. General guidelines when trying to communicate with the aphasic client include speaking more slowly and allowing adequate response time, listening to and watching attempts to communicate, and trying to put the client at ease with a caring and understanding manner. The nurse would avoid shouting (because the client is not deaf), appearing rushed for a response, and letting family members provide all the responses for the client.

23. A female client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as: a. Getting too little exercise b. Taking excess medication c. Omitting doses of medication d. Increasing intake of fatty foods

23. Answer C. Myasthenic crisis often is caused by undermedication and responds to the administration of cholinergic medications, such as neostigmine (Prostigmin) and pyridostigmine (Mestinon). Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Too little exercise and fatty food intake are incorrect. Overexertion and overeating possibly could trigger myasthenic crisis.

24. The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by: a. Eating large, well-balanced meals b. Doing muscle-strengthening exercises c. Doing all chores early in the day while less fatigued d. Taking medications on time to maintain therapeutic blood levels

24. Answer D. Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress.

25. A male client with Bell's palsy asks the nurse what has caused this problem. The nurse's response is based on an understanding that the cause is: a. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem b. Unknown, but possibly includes long-term tissue malnutrition and cellular hypoxia c. Primary genetic in origin, triggered by exposure to meningitis d. Primarily genetic in origin, triggered by exposure to neurotoxins

25. Answer A. Bell's palsy is a one-sided facial paralysis from compression of the facial nerve. The exact cause is unknown, but may include vascular ischemia, infection, exposure to viruses such as herpes zoster or herpes simplex, autoimmune disease, or a combination of these factors.

26. The nurse has given the male client with Bell's palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client states that he or she will: a. Exposure to cold and drafts b. Massage the face with a gentle upward motion c. Perform facial exercises d. Wrinkle the forehead, blow out the cheeks, and whistle

26. Answer A. Prevention of muscle atrophy with Bell's palsy is accomplished with facial massage, facial exercises, and electrical stimulation of the nerves. Exposure to cold or drafts is avoided. Local application of heat to the face may improve blood flow and provide comfort.

27. Female client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. The nurse inquires during the nursing admission interview if the client has history of: a. Seizures or trauma to the brain b. Meningitis during the last 5 years c. Back injury or trauma to the spinal cord d. Respiratory or gastrointestinal infection during the previous month.

27. Answer D. Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. Occasionally, the syndrome can be triggered by vaccination or surgery.

28. A female client with Guillian-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with this illness? a. Giving client full control over care decisions and restricting visitors b. Providing positive feedback and encouraging active range of motion c. Providing information, giving positive feedback, and encouraging relaxation d. Providing intravaneously administered sedatives, reducing distractions and limiting visitors

28. Answer C. The client with Guillain-Barré syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client's condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well.

For a client with a head injury whose neck has been stabilized, the preferred bed position is:

30-degree head elevation.

4. A female client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond? a. "You may have difficulty believing this, but the paralysis caused by this disease is temporary." b. "You'll have to accept the fact that you're permanently paralyzed. However, you won't have any sensory loss." c. "It must be hard to accept the permanency of your paralysis." d. "You'll first regain use of your legs and then your arms."

4. Answer A. The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.

5. The nurse is working on a surgical floor. The nurse must logroll a male client following a: a. laminectomy. b. thoracotomy. c. hemorrhoidectomy. d. cystectomy.

5. Answer A. The client who has had spinal surgery, such as laminectomy, must be logrolled to keep the spinal column straight when turning. The client who has had a thoracotomy or cystectomy may turn himself or may be assisted into a comfortable position. Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities immediately after surgery.

A nurse is planning to provide instructions to the client how to stand on crutches. In the written instructions, the nurse plans to tell the client to place the crutches:

6-10 inches in front and to the side of the client depending on the body size. This provides a base of support to the client and improves balance

7. During a routine physical examination to assess a male client's deep tendon reflexes, the nurse should make sure to: a. use the pointed end of the reflex hammer when striking the Achilles tendon. b. support the joint where the tendon is being tested. c. tap the tendon slowly and softly d. hold the reflex hammer tightly.

7. Answer B. To prevent the attached muscle from contracting, the nurse should support the joint where the tendon is being tested. The nurse should use the flat, not pointed, end of the reflex hammer when striking the Achilles tendon. (The pointed end is used to strike over small areas, such as the thumb placed over the biceps tendon.) Tapping the tendon slowly and softly wouldn't provoke a deep tendon reflex response. The nurse should hold the reflex hammer loosely, not tightly, between the thumb and fingers so it can swing in an arc.

8. A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority in this client's plan of care? a. Disturbed sensory perception (visual) b. Self-care deficient: Dressing/grooming c. Impaired verbal communication d. Risk for injury

8. Answer D. Because the client is disoriented and restless, the most important nursing diagnosis is risk for injury. Although the other options may be appropriate, they're secondary because they don't immediately affect the client's health or safety.

9. A female client with amyotrophic lateral sclerosis (ALS) tells the nurse, "Sometimes I feel so frustrated. I can't do anything without help!" This comment best supports which nursing diagnosis? a. Anxiety b. Powerlessness c. Ineffective denial d. Risk for disuse syndrome

9. Answer B. This comment best supports a nursing diagnosis of Powerlessness because ALS may lead to locked-in syndrome, characterized by an active and functioning mind locked in a body that can't perform even simple daily tasks. Although Anxiety and Risk for disuse syndrome may be diagnoses associated with ALS, the client's comment specifically refers to an inability to act autonomously. A diagnosis of Ineffective denial would be indicated if the client didn't seem to perceive the personal relevance of symptoms or danger.

What is TRIGEMINAL NEURALGIA? What are the considerations?

A cranial nerve disorder affecting sensory branches of the trigeminal nerve (CN V). Lukewarm food, chew on unaffected side, eye care, tearing, blinking, oral hygiene, increased protein, calories, room temperature and avoid touching client.

A 17-year-old high school junior was involved in a motor-vehicle collision and brought to the ED via squad. His left arm was severely traumatized in the accident and he was taken immediately to surgery. He is admitted to the ICU where you practice nursing and the physician has ordered close monitoring for compartment syndrome. What musculoskeletal structure does compartment syndrome affect? a) Nerve b) All options are correct c) Bone d) Ligament

A) Nerve Explanation: Compartment syndrome affects nerve innervation, leading to subsequent palsy (decreased sensation and movement).

The post-amputation client is seen by the home health nurse. One client outcome included preventing exposure to infection. Which finding would indicate to the nurse that this outcome was met? a) Decreased need for pain medication b) Absence of fever c) Decreased activity tolerance d) Increased participation in self- care

Absence of fever Explanation: Fever would be an indication of infection.

Which of these prescribed interventions will the nurse implement first for a hospitalized patient who is experiencing continuous tonic-clonic seizures?

Administer lorazepam (Ativan) 4 mg IV. rational: To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Phenytoin also will be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are nonresponsive, although the nurse should assess LOC after the seizure.

What should you make sure to discuss with someone who has multiple sclerosis?

Advanced directives because patient will eventually end up on vent and the use of a peak flow meter.

What is motor aphasia?

Also known as EXPRESSIVE APHASIA, Broca's area, it is the inability to speak or write. However, patient can comprehend the spoken or written form of communication.

What is AMYOTROPHIC LATERAL SCLEROSIS? What is important to know about it?

Also known as Lou Gehrig's Disease, it is a progressive neurological disease characterized by neuron death resulting in muscle weakness and eventually paralysis. The patient will die when respiratory paralysis reaches diaphragm so discuss advance directives and make sure to check gag reflex before feeding this patient.

What is sensory aphasia?

Also known as RECEPTIVE APHASIA, a patient cannot understand oral or written forms of communication.

What is autonomic dysreflexia? What is the cause? What are the signs and symptoms?

Also known as hyperreflexia, it is a potentially life threatening condition involving exaggeration of the sympathetic response to stimulation. The condition occurs in people with spinal cord injuries at T-6 or higher. It is triggered by a sustained stimuli such as restrictive clothing, pressure areas, FULL BLADDER, UTI or FECAL IMPACTION. Signs and symptoms above the level of injury: 1) flushed face 2) increased blood pressure 200/100 3) headache 4) distended neck veins 5) decreased heart rate 6) increased sweating, vasodilation Signs and symptoms below level of injury: 1. Pale 2. Cool 3. No sweating, vasoconstriction

The nurse is caring for an elderly client who exhibits signs of dementia. The most common cause of dementia in an elderly client is:

Alzheimer's disease.

What is Guillain Barre Syndrome?

An autoimmune disease of the nervous system due to damage of myelin sheath around the nerves., progresses rapidly or over 2-3 weeks, characterized by muscle weakness or symmetrical paralysis. Pig Head. Also, Landry's paralysis, an acute polyneuropathy affecting the PNS. The most typical symptoms cause change in sensation or pain, as well as dysfunction of the ANS. It can cause complications, in particularly in the respiratory muscles if the ANS is involved. It is usually triggered by an infection.

6. A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test? a. Immobilize the neck before the client is moved onto a stretcher. b. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. c. Place a cap over the client's head. d. Administer a sedative as ordered.

Answer B. Because CT commonly involves use of a contrast agent, the nurse should determine whether the client is allergic to iodine, contrast dyes, or shellfish. Neck immobilization is necessary only if the client has a suspected spinal cord injury. Placing a cap over the client's head may lead to misinterpretation of test results; instead, the hair should be combed smoothly. The physician orders a sedative only if the client can't be expected to remain still during the CT scan.

2. The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to: a. take a hot bath. b. rest in an air-conditioned room c. increase the dose of muscle relaxants. d. avoid naps during the day

Answer B. Fatigue is a common symptom in clients with multiple sclerosis. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with multiple sclerosis include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity.

3. A male client is having a tonic-clonic seizures. What should the nurse do first? a. Elevate the head of the bed. b. Restrain the client's arms and legs. c. Place a tongue blade in the client's mouth. d. Take measures to prevent injury.

Answer D. Protecting the client from injury is the immediate priority during a seizure. Elevating the head of the bed would have no effect on the client's condition or safety. Restraining the client's arms and legs could cause injury. Placing a tongue blade or other object in the client's mouth could damage the teeth

A patient seen at the health clinic with a severe migraine headache tells the nurse about having four similar headaches in the last 3 months. Which initial action should the nurse take?

Ask the patient to keep a headache diary. rational: The initial nursing action should be further assessment of the precipitating causes of the headaches, quality, and location of pain, etc. Stress reduction, muscle relaxation, and the triptan drugs may be helpful, but more assessment is needed first.

Which action will the nurse include in the plan of care when caring for a patient who is experiencing trigeminal neuralgia?

Assess intake and output and dietary intake. rational: The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink, so assessment of nutritional and hydration status is important. Because stimulation by touch is the precipitating factor for pain, relaxation of the facial muscles will not improve symptoms. Application of ice is likely to precipitate pain. The patient will not want to engage in conversation, which may precipitate attacks.

When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority?

Assessment of respiratory rate and depth rational: Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions also are appropriate but are not as important as assessment of respiratory effort.

A client diagnosed with a brain tumor experiences a generalized seizure while sitting in a chair. How should the nurse intervene first?

Assist the client to a side-lying position on the floor, and protect her with linens.

A client with a history of epilepsy is admitted to the medical-surgical unit. While assisting the client from the bathroom, the nurse observes the start of a tonic-clonic seizure. Which nursing interventions are appropriate for this client?

Assist the client to the floor. Turn the client to his side. Place a pillow under the client's head.

A patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?

Assist with active range of motion. rational: ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help to maintain strength as long as possible. Psychotic symptoms such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patient's ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.

A patient found in a tonic-clonic seizure reports afterward that the seizure was preceded by numbness and tingling of the arm. The nurse knows that this finding indicates what type of seizure?

Atonic rational: The initial symptoms of a partial seizure involve clinical manifestations that are localized to a particular part of the body or brain. Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities.

If a dislocation is not treated promptly, tissue death due to anoxia can occur. This would be documented as which of the following? a) Heterotopic ossification b) Osteomyelitis c) Subluxation d) Avascular necrosis (AVN)

Avascular necrosis (AVN) Explanation: If a dislocation is not treated promptly, AVN, tissue death due to anoxia and diminished blood supply, and nerve palsy may occur. Subluxation is a partial dislocation of the articulating surfaces. Heterotopic ossification is the abnormal formation of bone, near bones or in muscle, in response to soft tissue trauma after blunt trauma, fracture, or total joint replacement. Osteomyelitis is an acute or chronic inflammation of the bone caused by infection.

Why should the patient with trigeminal neuralgia chew on the unaffected side? What is the outcome?

Because the unaffected side is painful. Patient would lose weight. The outcome should be weight gain as a result of chewing on unaffected side and eating a high calorie, high protein diet like custard, milk and eggs.

How does GBS progress?

Begins in lower extremities and ascends bilaterally starting with weakness, then ataxia, then bilateral paresthesia progressing in paralysis.

What is BELLS PALSY? What are the considerations?

Bell's palsy is a form of facial paralysis resulting from a dysfunction of the cranial nerve VII (the facial nerve) causing an inability to control facial muscles on the affected side. The biggest complications are pain and an eyelid that won't shut. To protect the eyes from corneal abrasions, use drops and eye patches at night or tape shut to protect.

What is the most famous type of skin traction?

Buck's (used most often with hip and femoral fractures) Must do a good skin assessment with these

Pre-op notes about Total Hip Replacement: what type of traction is used?

Buck's is frequently used

A patient with a history of a T2 spinal cord injury tells the nurse, "I feel awful today. My head is throbbing, and I feel sick to my stomach." Which action should the nurse take first?

Check the blood pressure (BP). rational: The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is occurring. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used to prevent further increases in the BP.

In a patient with a dislocation, the nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable. Which of the following complications do the assessments help the nurse to monitor in the patient? a) Compartment syndrome b) GI bleeding c) Ganglion cysts d) Carpal tunnel syndrome

Compartment syndrome Explanation: The nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable in a patient with a dislocation to assess for compartment syndrome. It is a complication associated with dislocation. A patient with a dislocation does not experience an increased risk of complications such as GI bleeding, carpal tunnel syndrome, or ganglion cysts.

Which assessment findings would cause the nurse to suspect compartment syndrome after casting of the leg? a) Warm, pink foot and ability to move toes of affected leg b) Low-grade fever, dyspnea, tachycardia, and crackles c) Increased capillary refill and bounding pulses in affected leg d) Complaints of numbness and tingling in toes of affected leg

Complaints of numbness and tingling in toes of affected leg Explanation: Numbness and tingling indicate nerve ischemia and edema, suggesting development of compartment syndrome.

A 13-year-old client is brought to the emergency department. The client's mother reports that the client was struck with a baseball bat on his upper arm while diving for a pitched ball. After diagnostic tests are completed, the physician reassures the mother that her son's humerus is not broken but he has suffered another type of injury. What type of injury would you expect the physician to diagnose? a) Sprain b) Strain c) Contusion d) Subluxation

Contusion Explanation: A contusion is a soft tissue injury resulting from a blow or blunt trauma.

Which of the following is a term used to describe a soft tissue injury produced by a blunt force? a) Sprain b) Hematoma c) Contusion d) Strain

Contusion Explanation: A contusion is a soft tissue injury produced by blunt force, such as a blow, kick, or fall, that results in bleeding into soft tissues (ecchymosis, or bruising). A hematoma develops when the bleeding is sufficient to form an appreciable solid swelling. A strain, or a "pulled muscle," is an injury to a musculotendinous unit caused by overuse, overstretching, or excessive stress. A sprain is an injury to the ligaments and supporting muscle fibers that surround a joint often caused by a trauma, wrenching or twisting motion.

A client presents to the emergency department with an open fracture. What is the first action the nurse should take? a) Assess the client's vital signs and determine allergies. b) Cover the exposed bone with sterile dressing. c) Perform a neurovascular assessment of the affected extremity. d) Assist the physician with reduction of the fracture.

Cover the exposed bone with sterile dressing. Explanation: The exposed bone should be covered with a sterile dressing to protect the deeper tissues from contamination.

What is the medical treatment for TRIGEMINAL NEURALGIA? What is the surgical treatment?

DILANTIN or TEGRETOL. For surgical, local nerve blocks or slow nerve transmission to decrease pain.

What is important to teach pregnant women about DILANTIN?

DO NOT TAKE, because it causes birth defects.

A client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test?

Determine whether the client is allergic to iodine, contrast dyes, or shellfish.

A patient tells the nurse about using acetaminophen (Tylenol) several times every day for recurrent bilateral headaches. Which action will the nurse plan to take first?

Discuss the need to stop taking the acetaminophen. rational: The headache description suggests that the patient is experiencing medication overuse headache. The initial action will be withdrawal of the medication. The other actions may be needed if headaches persist.

A client who suffers an injury in a local high school hockey game presents with left shoulder pain. The client cannot move the left arm, and the left shoulder is lower than the right shoulder. The nurse recognizes the client most likely has a: a) Clavicle fracture b) Dislocated elbow c) Dislocated shoulder d) Cervical injury

Dislocated shoulder Explanation: Clinical manifestations of a dislocated shoulder include pain, lack of motion, feeling of an empty shoulder socket, and uneven posture.

A 39-year-old client has been brought to the ED by his teammates. The client was fielding a fly ball, fell, and injured his hip. He cannot place weight on the leg and is in significant pain. After radiographs indicated intact but malpositioned bones, what would you expect the physician to diagnose? a) Fracture b) Strain c) Sprain d) Dislocation

Dislocation Explanation: In joint dislocation, radiographic films show intact yet malpositioned bones.

A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease?

Edrophonium (Tensilon)

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?

Elevated 30 degrees

A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative care plan? a) Maintaining the client on complete bed rest b) Elevating the stump for the first 24 hours c) Removing the pressure dressing after the first 8 hours d) Applying heat to the stump as the client desires

Elevating the stump for the first 24 hours Explanation: Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing venous return and decreasing venous pooling at the distal portion of the extremity. Bed rest isn't indicated and could predispose the client to complications of immobility. Heat application would be inappropriate because it promotes vasodilation, which may cause hemorrhage and increase pain. The initial pressure dressing usually remains in place for 48 to 72 hours after surgery.

Which of the following are general nursing measures for a patient with a fracture reduction? a) Promoting intake of omega-3 fatty acids b) Encourage participation in ADLs c) Examining the abdomen for enlarged liver or spleen d) Assisting with intake of immune-enhancing tube feeding formulas

Encourage participation in ADLs Explanation: General nursing measures for a patient with a fracture reduction include administering analgesics, providing comfort measures, encouraging participation with ADLs, promoting physical mobility, preventing infection, maintaining skin integrity, and preparing the patient for self-care. Omega-3 fatty acids have no implications on the diet of a patient with a fracture reduction. The nurse should not examine the abdomen for enlarged liver or spleen since fracture reduction treatment does not affect these organs. It is unlikely that a patient with a fracture reduction will be prescribed immune-enhancing tube feeding formulas.

A client is hospitalized with Guillain-Barré syndrome. Which data collection finding is most significant?

Even, unlabored respirations

Which action should the nurse take when assessing a patient with trigeminal neuralgia?

Examine the mouth and teeth thoroughly. rational: Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the patient clench the facial muscles will not be useful because the sensory branches of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided.

A client with seizure disorder comes to the physician's office for a routine checkup. Knowing that the client takes phenytoin (Dilantin) to control seizures, the nurse assesses for which common adverse drug reaction?

Excessive gum tissue growth

What makes someone with myasthenia gravis worse?

Exercise and Infection

A client with a fracture develops compartment syndrome that requires surgical intervention. The nurse would most likely prepare the client for which of the following? a) Amputation b) Joint replacement c) Bone graft d) Fasciotomy

Fasciotomy Explanation: Surgical treatment of compartment syndrome is achieved with a fasciotomy, a surgical incision of the fascia and separation of the muscle to relieve pressure and restore tissue perfusion. Bone graft, joint replacement or amputation may be done for a client who experiences avascular necrosis.

The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a patient who has sustained a fracture. The nurse suspects which complication? a) Fat embolism syndrome b) Hypovolemic shock c) Reflex sympathetic dystrophy syndrome d) Compartment syndrome

Fat embolism syndrome Explanation: Cerebral disturbances in the patient with fat embolism syndrome include subtle personality changes, restlessness, irritability, and confusion. With compartment syndrome, the patient complains of deep, throbbing, unrelenting pain. With hypovolemic shock, the patient would have a decreased blood pressure and increased pulse rate. Clinical manifestations of reflex sympathetic dystrophy syndrome include severe, burning pain, local edema, hyperesthesia, muscle spasms, and vasomotor skin changes.

The nurse is assigned to care for a client with early stage Alzheimer's disease. Which nursing interventions should be included in the client's care plan?

Furnish the client's environment with familiar possessions., Assist the client with activities of daily living (ADLs) as necessary., Assign tasks in simple steps.

If someone with GBS has voiding problems, what should you be concerned about?

Get a vent in place because diaphragm is going to be affected next.

What are the adverse reactions from medication?

Gingival hyperplasia, GI disturbances, heptoxicity, ataxia, hypocalcemia, and decrease in vitamin D absorption

What should you teach a patient on DILANTIN?

Good oral hygiene and nutrition are important

Which of the following terms refers to a fracture in which one side of a bone is broken and the other side is bent? a) Avulsion b) Oblique c) Greenstick d) Spiral

Greenstick Explanation: A greenstick fracture is a fracture in which one side of a bone is broken and the other side is bent. A spiral fracture is a fracture twisting around the shaft of the bone. An avulsion is the pulling away of a fragment of bone by a ligament or tendon and its attachment. An oblique is a fracture occurring at an angle across the bone.

How can you keep your patient safe during seizure?

Have airway open, clear harmful objects, assess respirations and then pulse. Do not restrain patient during seizure. Do not try to open clenched jaw. Do not move unless it is unsafe not to move. Do not suction until motor activity stops.

A patient with mild dementia has a new prescription for donepezil (Aricept). Which nursing action will be most effective in ensuring compliance with the medication?

Having the patient's spouse administer the medication rational: Because the patient with mild dementia will have difficulty with learning new skills and forgetfulness, the most appropriate nursing action is to have someone else administer the drug. The other nursing actions will not be as effective in ensuring that the patient takes the medications.

A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?

Helicopod

A client undergoes cerebral angiography to evaluate for neurologic deficits. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?

Hemiplegia, seizures, and decreased level of consciousness (LOC)

A patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching?

How to draw up and administer injections of the medication rational: Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for birth control. There is no need to avoid driving or drink large fluid volumes when taking glatiramer.

When evaluating for hypovolemic shock, the nurse should be aware of which of the following clinical manifestations? a) Hypertension b) Bradycardia c) Bounding pulse d) Hypotension

Hypotension Explanation: The nurse should be alert to a weak pulse (thread), decreased blood pressure, decreased urine output, rapid, shallow respirations, and elevated heart rate.

A client in a nursing home is diagnosed with Alzheimer's disease. He exhibits the following symptoms: difficulty with recent and remote memory, irritability, depression, restlessness, difficulty swallowing, and occasional incontinence. This client is in what stage of Alzheimer's disease?

II

What is the proper way to give DILANTIN?

IV Push: (not compatible with IV solutions), give closest insertion site, flush/push/flush

A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barré syndrome. The nurse will anticipate the need to teach the patient about _____________

IV infusion of immunoglobulin (Sandoglobulin). rational: Because the Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or symptoms of the syndrome.

A patient with Parkinson's disease has decreased tongue mobility and an inability to move the facial muscles. Which nursing diagnosis is of highest priority?

Imbalanced nutrition: less than body requirements rational: The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other diagnoses also may be appropriate for a patient with Parkinson's disease, but the data do not indicate they are current problems for this patient.

Shortly after admission to an acute care facility, a client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium), 10 mg I.V. stat. How soon can the nurse administer a second dose of diazepam, if needed and prescribed?

In 10 to 15 minutes

Compartment Syndrome

Increased pressure within a limited space

In a client with amyotrophic lateral sclerosis and respiratory distress, which finding is the earliest sign of reduced oxygenation?

Increased restlessness

Which nursing diagnosis takes highest priority for a client with Parkinson's crisis?

Ineffective airway clearance

While admitting a patient with a basal skull fracture, the nurse notes clear drainage from the patient's nose. Which of these admission orders should the nurse question?

Insert nasogastric tube. rational: Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage, and insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold pack are appropriate orders.

A physician diagnoses a client with myasthenia gravis and prescribes pyridostigmine (Mestinon), 60 mg by mouth every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the client's history. Which preexisting condition would contraindicate the use of pyridostigmine?

Intestinal obstruction

What is an aura?

It is a foreknowledge that a seizure is going to occur

What is PARKINSON'S DISEASE?

It is a progressive neurological disease with a slow onset that usually occurs after age 50, rarely occurring in the black population, and leading to a respiratory death. The motor symptoms of Parkinson's disease result from the death of dopamine-generating cells in the substantia nigra, a region of the midbrain; the cause of this cell death is unknown.

What is multiple sclerosis?

It is a progressive neurological disease with an onset among those who are at their 20's through 40's. It has a hereditary link and occurs most commonly among women. It involves the hardening of multiple nerves, and is aggravated by stress. It limits changes.

What is myasthenia gravis?

It is an autoimmune neuromuscular disease that affects the motor cranial nerves. It is the GRAVE MUSCLE WEAKNESS. Exacerbation and remissions are parts of the disease which tend to be progressive over time.

A 39-year-old softball player has been brought to the ED by his teammates. The client was fielding a fly ball, fell, and injured his hip. He cannot place weight on the leg and is in significant pain. After radiographs indicate intact yet malpositioned bones, what repair would you expect the physician to perform? a) Analgesia and immobilization b) Joint manipulation and immobilization c) Heat and immobilization d) Ice and immobilization

Joint manipulation and immobilization Explanation: The physician manipulates the joint or reduces the displaced parts until they return to normal position, then immobilizes the joint with an elastic bandage, cast, or splint for several weeks.

During the morning change-of-shift report at the long-term care facility, the nurse learns that the patient with dementia has had sundowning. Which nursing action should the nurse take while caring for the patient?

Keep blinds open during the daytime hours. rational: The most likely cause of sundowning is a disruption in circadian rhythms and keeping the patient active and in daylight will help to reestablish a more normal circadian pattern. Moving the patient to a different room might increase confusion. Taking a nap will interfere with nighttime sleep. Hourly orientation will not be helpful in a patient with memory difficulties.

A client undergoes hip-pinning surgery to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan? a) Keeping a pillow between the client's legs at all times b) Maintaining the client in semi-Fowler's position c) Turning the client from side to side every 2 hours d) Performing passive range-of-motion (ROM) exercises on the client's legs once each shift

Keeping a pillow between the client's legs at all times Explanation: After hip pinning, the client must keep the affected leg abducted at all times; placing a pillow between the legs reminds the client not to cross the legs and to keep the leg abducted. Passive or active ROM exercises shouldn't be performed on the affected leg during the postoperative period because this could damage the operative site and cause hip dislocation. Most clients should be turned to the unaffected side, not from side to side. After hip pinning, the client must avoid acute flexion of the affected hip to prevent possible hip dislocation; therefore, semi-Fowler's position should be avoided.

The nurse should include which intervention in the postoperative care plan of a patient after hip pinning? a) Keeping a pillow between the client's legs at all times b) Turning the client from side to side every 2 hours c) Maintaining the client in semi-Fowler's position d) Performing passive range-of-motion (ROM) exercises on the client's legs once each shift

Keeping a pillow between the client's legs at all times Explanation: After hip pinning, the client must keep the affected leg abducted at all times; placing a pillow between the legs reminds the client not to cross the legs and to keep the leg abducted. Passive or active ROM exercises shouldn't be performed on the affected leg during the postoperative period because this could damage the operative site and cause hip dislocation. Most clients should be turned to the unaffected side, not from side to side. After hip pinning, the client must avoid acute flexion of the affected hip to prevent possible hip dislocation; therefore, semi-Fowler's position should be avoided.

What drug is commonly taken to help Parkinson's symptoms? What are the Considerations?

LEVODOPA. Watch for hypotension and place TED hose on your patient to prevent further complications.

Which of the following is an inaccurate clinical manifestation of a fracture? a) Lengthening b) Deformity c) Pain d) Crepitus

Lengthening Explanation: Clinical manifestations of a fracture include crepitus, deformity pain, shortening, and loss of function.

Which of the following is a factor that inhibits fracture healing? a) Vitamin D b) Maximum bone fragment contact c) Local malignancy d) Exercise

Local malignancy Explanation: Factors that inhibit fracture healing include local malignancy, bone loss, and extensive local trauma. Factors that enhance fracture healing include proper nutrition, vitamin D, exercise, and maximum bone fragment contact.

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. In this syndrome, polyneuritis leads to progressive motor, sensory, and cranial nerve dysfunction. On admission, which assessment is most important for this client?

Lung auscultation and measurement of vital capacity and tidal volume

Which nursing intervention is appropriate for minimizing muscle spasms in the client with a hip fracture? a) Assist the client with use of a trapeze. b) Maintain the internal fixator. c) Apply a soft compression dressing. d) Maintain Buck's traction.

Maintain Buck's traction. Explanation: Buck's traction decreases pain, muscle spasm, and external rotation by immobilizing the hip fracture.

Which intervention will the nurse include in the plan of care for a patient who has late-stage Alzheimer's disease (AD)?

Maintain a consistent daily routine for the patient's care. rational: Providing a consistent routine will decrease anxiety and confusion for the patient. In late-stage AD, the patient will not remember events from the past. Reorientation to time and place will not be helpful to the patient with late-stage AD, and the patient will not be able to read.

What should you do first if a pregnant woman starts thrashing in bed?

Make sure the patient is side lying

A client with tonic-clonic seizure disorder is being discharged with a prescription for phenytoin (Dilantin). Which instructions about phenytoin should the nurse give this client?

Monitor for skin rash. Perform good oral hygiene, including daily brushing and flossing., Periodic follow-up blood work is necessary. Report to the physician problems with walking and coordination, slurred speech, or nausea.

Pin care

Monitor the site sterile technique remove crusts serous drainage is ok

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?

Monitoring the patency of an indwelling urinary catheter

What are the risk factors for Guillain Barre Syndrome?

More common among the 20-50 age group, associated with swine flu immunizations, frequently preceded by mild respiratory or intestinal infection.

When joint manipulation is unsuccessful for a client, he is taken to surgery for surgical repair of his hip injury. He is brought to the ICU where you practice nursing for postoperative recovery. In addition to the regular assessments prescribed by policy, what assessment is completed every 30 minutes for several hours? a) Neurological b) Neurovascular c) Orientation d) Head-to-toe

Neurovascular Explanation: The nurse should perform neurovascular assessments every 30 minutes for several hours, and then at least every 2 to 4 hours for the next 1 or 2 days to detect complications.

A patient with right-sided weakness that started 90 minutes earlier is admitted to the emergency department and all these diagnostic tests are ordered. Which test should be done first?

Noncontrast computed tomography (CT) scan rational: Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.

Following a thymectomy, a patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first?

Notify the patient's health care provider. rational: The patient's history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis.

When the nurse is assessing a patient with myasthenia gravis, which action will be most important to take?

Observe respiratory effort. rational: Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.

A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. Which action will the nurse take first?

Obtain oxygen saturation. rational: Airway patency and breathing are the most vital functions and should be assessed first. The neurologic assessments should be accomplished next and the health and medication history last.

What drug is used by someone experiencing autonomic dysreflexia symptoms at home?

PROCARDIA to decrease BP. Prick and squeeze under tongue. Works quickly and raise head of bed.

Which of these nursing actions for a patient with Guillain-Barré syndrome is most appropriate for the nurse to delegate to an experienced nursing assistant?

Passive range of motion to extremities q8hr rational: Assisting a patient with movement is included in nursing assistant education and scope of practice. Administration of tube feedings, administration of ordered medications, and assessment are skills requiring more education and scope of practice, and the RN should perform these skills.

What occurs in the post-ictal period?

Patient sleeps for several hours after seizure. Do not call physician because this is expected.

Elderly clients who fall are most at risk for which injuries? a) Cervical spine fractures b) Pelvic fractures c) Wrist fractures d) Humerus fractures

Pelvic fractures Explanation: Elderly clients who fall are most at risk for pelvic and lower extremity fractures. These injuries are devastating because they can seriously alter an elderly client's lifestyle and reduce functional independence. Wrist fractures usually occur with falls on an outstretched hand or from a direct blow. Such fractures are commonly found in young men. Humerus fractures and cervical spine fractures aren't age-specific.

When assessing a patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility, the nurse learns that the patient has had several episodes of wandering away from home. Which nursing action will the nurse include in the plan of care?

Place the patient in a room close to the nurses' station. rational: Patients at risk for problems with safety require close supervision. Placing the patient near the nurse's station will allow nursing staff to observe the patient more closely. The use of "why" questions is frustrating for patients with AD because they are unable to understand clearly or verbalize the reason for wandering behaviors. Because of the patient's short-term memory loss, reorientation will not help prevent wandering behavior. Because the patient had wandering behavior at home, familiar objects will not prevent wandering.

A client with amyotrophic lateral sclerosis (ALS) tells the nurse, "Sometimes I feel so frustrated. I can't do anything without help!" This comment best supports which nursing diagnosis?

Powerlessness

A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take?

Prepare the patient for immediate craniotomy. rational: The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary.

Which information about a patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse?

Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg rational: The PbtO2 should be 20 to 40 mm Hg. Lower levels indicate brain ischemia. An intracranial pressure (ICP) of 15 mm Hg is at the upper limit of normal. CSF is produced at a rate of 20 to 30 mL/hour. The reason for the sinus tachycardia should be investigated, but the elevated heart rate is not as concerning as the decrease in PbtO2.

A nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis? a) Prevent internal rotation of the affected leg. b) Keep the hip flexed by placing pillows under the client's knee. c) Use measures other than turning to prevent pressure ulcers. d) Keep the affected leg in a position of adduction.

Prevent internal rotation of the affected leg. Explanation: The nurse and other caregivers should prevent internal rotation of the affected leg. However, external rotation and abduction of the hip will help prevent dislocation of a new hip joint. Postoperative total hip replacement clients may be turned onto the unaffected side. The hip may be flexed slightly, but it shouldn't exceed 90 degrees. Maintenance of flexion isn't necessary.

Elevated sedimention rate, morning stiffness occure in

RA

When developing a plan of care for a hospitalized patient with moderate dementia, which intervention will the nurse include?

Remind the patient frequently about being in the hospital. rational: The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility.

Which nursing intervention is essential in caring for a client with compartment syndrome? a) Wrapping the affected extremity with a compression dressing to help decrease the swelling b) Starting an I.V. line in the affected extremity in anticipation of venogram studies c) Keeping the affected extremity below the level of the heart d) Removing all external sources of pressure, such as clothing and jewelry

Removing all external sources of pressure, such as clothing and jewelry Explanation: Nursing measures should include removing all clothing, jewelry, and external forms of pressure (such as dressings or casts) to prevent constriction and additional tissue compromise. The extremity should be maintained at heart level (further elevation may increase circulatory compromise, whereas a dependent position may increase edema). A compression wrap, which increases tissue pressure, could further damage the affected extremity. There is no indication that diagnostic studies would require I.V. access in the affected extremity.

What are the people with myasthenia gravis always at risk for?

Respiratory Distress

What kind of death does a person with multiple sclerosis normally die from?

Respiratory. Watch for hypoxia, restlessness, and agitation.

A client with Alzheimer's disease is admitted for hip surgery after falling and fracturing the right hip. The spouse tells the nurse of feeling guilty for letting the accident happen and reports not sleeping well because the spouse has been getting up at night and doing odd things. Which nursing diagnosis is most appropriate for the client's spouse?

Risk for caregiver role strain related to increased client care needs

The nurse is administering neostigmine to a client with myasthenia gravis. Which nursing intervention should the nurse implement?

Schedule the medication before meals.

What is DILANTIN used for?

Seizure prevention

What kind of shoes should you recommend for a patient with Parkinson's Disease?

Shoes with 1 thread so they can slide through lie. No tennis shoes or leather bottom shoes. Slippers are good.

What is the short term treatment for diagnosis of myasthenia gravis? And for long term?

Short term is TENSILON. Long term treatment is PROSTIGMIN, an airway medication and MESTINON.

How is the diagnosis of myasthenia gravis made versus cholinergic crisis?

Since both are present with the same symptoms, administer TENSILON to differentiate one from the other. If the symptoms improve, then it is myasthenia gravis. A lack of medication, PROSTIGMIN, would then be the problem. So, increase medication. If the symptoms get worse, then it is a cholinergic crisis. Too much medication is the problem with increased Prostigmin. So provide an antidote which is ATROPIN.

What kinds of food or vitamins should someone with Parkinson's avoid? Why?

Spinach, bananas, fish and pepper. Also, Vitamin B6, because they all deactivate LEVODOPA, the precursor to the neurotransmitters dopamine, norepinephrine (noradrenaline), and epinephrine (adrenaline) collectively known as catecholamines

A client sustains an injury to the ligaments surrounding a joint. The nurse identifies this as which of the following? a) Fracture b) Strain c) Sprain d) Contusion

Sprain Explanation: A sprain is an injury to the ligaments surrounding a joint. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. A contusion is a soft tissue injury resulting from a blow or blunt trauma. A fracture is a break in the continuity of a bone.

A hospitalized 24-year-old patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first?

Start the ordered PRN oxygen at 6 L/min. rational: Acute treatment for cluster headache is administration of 100% oxygen at 6 to 8 L/min. If the patient obtains relief with the oxygen, there is no immediate need to notify the health care provider. Cluster headaches last only 60 to 90 minutes, so oral pain medications have minimal effect. Hot packs are helpful for tension headaches but are not as likely to reduce pain associated with a cluster headache.

Types of Skeletal traction

Steinman pins Crutchfield Gardner-Wells tongs Halo vest

A 45-year-old softball player arrives at the emergency department following his injury while sliding into a base during a game. After his examination and radiographs, the physician diagnoses muscle strain and prescribes appropriate treatment. What does the physician mean with the term "strain"? a) Stretched or pulled beyond capacity b) Subluxation of a joint c) Injuries to ligaments surrounding a joint d) Injury resulting from a blow or blunt trauma

Stretched or pulled beyond capacity Explanation: A strain is an injury to a muscle when it is stretched or pulled beyond its capacity.

A client is scheduled for electroconvulsive therapy (ECT). Before ECT begins, the nurse expects which neuromuscular blocking agent to be administered?

Succinylcholine (Anectine)

A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside?

Suction machine with catheters

A patient with Parkinson's disease has a nursing diagnosis of impaired physical mobility related to bradykinesia. Which action will the nurse include in the plan of care?

Suggest that the patient rock from side to side to initiate leg movement. rational: Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait.

A client is having a tonic-clonic seizure. What should the nurse do first?

Take measures to prevent injury.

A patient with multiple sclerosis (MS) has urinary retention caused by a flaccid bladder. Which action will the nurse plan to take?

Teach the patient how to use the Credé method. rational: The Credé method can be used to improve bladder emptying. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection (UTI) and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying.

Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia in order to prevent autonomic dysreflexia?

Teach the purpose of a prescribed bowel program. rational: Fecal impaction is a common stimulus for autonomic dysreflexia. The other actions may be included in the plan of care but will not reduce the risk for autonomic dysreflexia.

A client has a fiberglass (nonplaster) cast applied to the lower leg. The client asks the nurse when he will be able to walk on the cast. The nurse replies that the client will be able to bear weight on the cast when?

The client can bear weight within 20 to 30 minutes of application

The health care provider is considering the use of sumatriptan (Imitrex) for a patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider?

The patient has a history of a recent acute myocardial infarction. rational: The triptans cause coronary artery vasoconstriction and should be avoided in patients with coronary artery disease. The other information will be reported to the health care provider, but none of it is an indication that sumatriptan would be an inappropriate treatment.

Which information about a patient with MS indicates that the nurse should consult with the health care provider before giving the prescribed dose of fampridine (Ampyra)?

The patient has an increased creatinine level. rational: Fampridine should not be given to patients with impaired renal function. The other information will not impact on whether the fampridine should be administered.

When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will require the most immediate action?

The patient has continuous drooling of saliva. rational: Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barré syndrome.

A patient has a new prescription for bromocriptine (Parlodel) to control symptoms of Parkinson's disease. Which information obtained by the nurse may indicate a need for a decrease in the dose?

The patient's blood pressure is 90/46 mm Hg. rational: Hypotension is an adverse effect of bromocriptine, and the nurse should check with the health care provider before giving the medication. Diarrhea, cough, and deep vein thrombosis are not associated with bromocriptine use.

A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which information about the patient is most important to communicate to the health care provider?

The patient's blood pressure is 90/50 mm Hg. rational: To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.

What should you document for a seizure occurrence?

The time it occurred and lasted and what parts of the body were affected.

Which information about a patient who is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease is most important for the nurse to report to the health care provider?

Uncontrolled head movement rational: Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease.

The nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding should the nurse consider abnormal?

Urine retention or incontinence

To determine whether a new patient's confusion is caused by dementia or delirium, which action should the nurse take?

Use the Confusion Assessment Method tool to assess the patient. rational: The Confusion Assessment Method tool has been extensively tested in assessing delirium. The other actions will be helpful in determining cognitive function or risk factors for dementia or delirium, but they will not be useful in differentiating between dementia and delirium.

What should you watch for with TEGETROL?

Used as an anticonvulsant for seizure prevention. Monitor CBC d/t bone marrow suppression and watch for infection

The nurse is collecting data on a 38-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find?

Vision changes

The nurse is planning care for a client with multiple sclerosis. Which three problems should the nurse expect the client to experience?

Visual disturbances Balance problems Mood disorders

Which of the following may occur if a client experiences compartment syndrome in an upper extremity? a) Subluxation b) Callus c) Volkmann's contracture d) Whiplash injury

Volkmann's contracture Explanation: If compartment syndrome occurs in an upper extremity, it may lead to Volkmann's contracture, a clawlike deformity of the hand resulting from obstructed arterial blood flow to the forearm and hand. A whiplash injury is a cervical spine sprain. Callus refers to the healing mass that occurs with true bone formation after a fracture. Subluxation refers to a partial dislocation.

Which of the following may occur if a client experiences compartment syndrome in an upper extremity? a) Volkmann's contracture b) Callus c) Subluxation d) Whiplash injury

Volkmann's contracture Explanation: If compartment syndrome occurs in an upper extremity, it may lead to Volkmann's contracture, a clawlike deformity of the hand resulting from obstructed arterial blood flow to the forearm and hand. A whiplash injury is a cervical spine sprain. Callus refers to the healing mass that occurs with true bone formation after a fracture. Subluxation refers to a partial dislocation.

How is multiple sclerosis treated?

With steroids when active. Patient then becomes immunocompromised.

Is someone with aphasia still considered competent?

YES

When teaching the children of a patient who is being evaluated for Alzheimer's disease (AD) about the disorder, the nurse explains that

a diagnosis of AD can be made only when other causes of dementia have been ruled out. rational: The diagnosis of AD is one of exclusion. Age is the most important risk factor for development of AD. Drugs can slow the deterioration but do not dramatically reverse the effects of AD. Brain atrophy is a common finding in AD, but it can occur in other diseases as well and does not confirm an AD diagnosis.

A client is admitted to the nursing unit after a l BKA following a crush injury to the foot and lower leg. The client says "I feel my left foot itching". The nurse interprets this how?

a normal response, and indicates the presence of phantom limb sensation.

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by:

a positive edrophonium (Tensilon) test.

A client is complaining of pain underneath a cast in the area of a bony prominence. The nurse interprets that this client may need to have what?

a window cut in the cast. A window may be cut in a dried cast to relieve pressure, monitor pulses, relieve discomfort, or remove drains

A hospitalized patient complains of a moderate bilateral headache that radiates from the base of the skull. Which of these prescribed PRN medications should the nurse administer initially?

acetaminophen (Tylenol) rational: The patient's symptoms are consistent with a tension headache, and initial therapy usually involves a nonopioid analgesic such as acetaminophen, sometimes combined with a sedative or muscle relaxant. Lorazepam may be used in conjunction with acetaminophen but would not be appropriate as the initial monotherapy. Morphine sulfate and butalbital and aspirin would be more appropriate for a headache that did not respond to a nonopioid analgesic.

A patient is seen in the health clinic with symptoms of a stooped posture, shuffling gait, and pill rolling-type tremor. The nurse will anticipate teaching the patient about _______________

antiparkinsonian drugs. rational: The diagnosis of Parkinson's is made when two of the three characteristic signs of tremor, rigidity, and bradykinesia are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. This patient has symptoms of tremor and bradykinesia; the next anticipated step will be treatment with medications. MRI and EEG are not useful in diagnosing Parkinson's disease, and corticosteroid therapy is not used to treat it.

The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to _______________

ask simple questions that the patient can answer with "yes" or "no." rational: Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.

A long-term care patient with moderate dementia develops increased restlessness and agitation. The nurse's initial action should be to

assess for factors that might be causing discomfort. rational: Increased motor activity in a patient with dementia is frequently the patient's only way of responding to factors like pain, so the nurse's initial action should be to assess the patient for any precipitating factors. Administration of sedative drugs may be indicated, but this should not be done until assessment for precipitating factors has been completed and any of these factors have been addressed. Reorientation is unlikely to be helpful for the patient with moderate dementia. Assigning a nursing assistant to stay with the patient also may be necessary, but any physical changes that may be causing the agitation should be addressed first.

The nurse witnesses a patient with a seizure disorder as the patient suddenly jerks the arms and legs, falls to the floor, and regains consciousness immediately. It will be most important for the nurse to _________________

assess the patient for a possible head injury. rational: The patient who has had a myoclonic seizure and fall is at risk for head injury and should be evaluated and treated for this possible complication first. Documentation of the seizure, notification of the seizure, and administration of antiseizure medications also are appropriate actions, but the initial action should be assessment for injury.

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:

carefully move him to a flat surface and turn him on his side.

Dislocation (after hip surgery)

circulatory/nerve damage S/S: shortening of leg, abnormal rotation, can't move extremity, PAIN

The client asks the nurse, "How does ergotamine (Ergostat) relieve migraine headaches?" The nurse should respond that it:

constricts cerebral blood vessels.

Should contraction be intermittent or continuous?

continuous! Never relieve traction without a doc's order

The nurse is teaching a client who has facial muscle weakness and has recently been diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by:

destruction of acetylcholine receptors.

Risk factors associated with osteoporosis

diet low in calcium sedentary lifestyle cigarette smoking long term alcohol assumption chronic illness longe term use of anticonvulsants and furosemide (Lasix)

A patient who is seen in the outpatient clinic complains of restless legs syndrome. Which of the following over-the-counter medications that the patient is taking routinely should the nurse discuss with the patient?

diphenhydramine (Benadryl) rational: Antihistamines can aggravate restless legs syndrome. The other medications will not contribute to the restless legs syndrome.

A client has had skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should monitor which the followin as a high-risk area for pressure and breakdown

elbows if they are used for repositioning instead of trapeze, heel of good leg whih is used as a brace when pushing up in bed. ischial tuberosity, popliteal space, and schilles tendon

A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order:

electromyography (EMG).

When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should:

elevate the head of the bed 90 degrees during meals.

A nurse is assigned to care for a client with multiple trauma who is admitted to the hospital. The client has a leg fracture, and a plaster cast had been applied. In positioning the casted leg , the nurse should do what

elevate the leg on pillow continuously for 24-48 hours

A nurse is caring for a client with fresh application of a plaster leg cast. THe nurse plans to prevent the development of compartment syndrom by doing what?

elevating the limb and applying ice to the affected leg. Compartment syndrom is prevented by controlling edema. This is acheived most optimally with elevation and application of ice

What is a fasciculation

fine muscle twitches that are not normally present

A client seeks tx in er department for a lower leg injury. There is visible deformity to the lower aspect of the leg and injured leg appears shorte than the other. The area is painful, swollen, and beginnin to become ecchymotic. The nurse interprets that this cliet has experienced a

fracture

A nurse is checking the casted extremity of a client. The nurse would check for which of the following signs and symptoms indicative of infection 1.edema 2. no distal pulses 3.hot spot on the cast

hot spot on the cast which are areas of the cast that are warmer than others

If a nonplaster (fiberglass) gets wet the client can dry it how

if the cast gets wet, it can be dried with a hair dryer set to a COOL setting to prevent skin breakdown.

A nurse witnesses a client sustain a fall and suspects that the client's leg may be fractures. Which action is the priority

immobilize the leg before moving the client

A nurse suspects that a client with a recent fracture has compartment syndrome. Assessment findings may include: a) body-wide decrease in bone mass. b) inability to perform active movement and pain with passive movement. c) a growth in and around the bone tissue. d) inability to perform passive movement and pain with active movement.

inability to perform active movement and pain with passive movement. Explanation: With compartment syndrome, the client can't perform active movement, and pain occurs with passive movement. A body-wide decrease in bone mass is seen in osteoporosis. A growth in and around the bone tissue may indicate a bone tumor.

A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse s response is based on the understand that this could result in

injury to the brachial plexus nerves

When obtaining a health history and physical assessment for a patient with possible multiple sclerosis (MS), the nurse should _____________

inquire about any urinary tract problems. rational: Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.

A nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Include what instructions for patien

keep cast and extremity elevate the cast needs to be kept clean and dry allow the wet cast 24 hours to 72 hours to dry

The nurse is working on a surgical floor. The nurse must logroll a client following a:

laminectomy.

What is worn under the prosthesis?

limb sock

A 72-year-old patient is diagnosed with moderate dementia as a result of multiple strokes. During assessment of the patient, the nurse would expect to find _____________

loss of both recent and long-term memory. rational: Loss of both recent and long-term memory is characteristic of moderate dementia. Patients with dementia have frequent nighttime awakening. Dementia is progressive, and the patient's ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia.

The edges of a cast can be petaled with tape to do what

minimize skin iritation

What is nursing care after bone biopsy

mointoy site for swelling, bleeding, and hematoma formation elevate site for 24 hours to reduce edem monitor vitals every four hourse for 24 hours. The client usually requires mild analgesics, more sever pain usually indicates that complication are arising

What assessment is most important with fractures?

neuro-vascular checks -Pulse, Color, Movement, Sensation, Cap refill, and temp

A clietn has had a bone scan procedure. What is the after care

no specific aftercare. Encourage client to drink large amounts of water for 24-48 hours to flush the radiosotope from the system. There are no hazards to the clietn or staff from the minimal amount of radioactivity of the isotope

A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the patient's illness, the most essential assessment for the nurse to carry out is ______________

observing respiratory rate and effort. rational: The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments also will be included in nursing care, but they are not as important as respiratory assessment.

The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include ______________

oral administration of low dose aspirin therapy. rational: The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.

Morning stiffness occurs in

osteoarthritis

A client with a sprain but not fracture should be told to do what before being sent home

patien should be taughts to rest, ice, compress, and elevate SPRIAN=RICE

When teaching a patient with myasthenia gravis (MG) about management of the disease, the nurse advises the patient to ______________

perform physically demanding activities in the morning. rational: Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled but is used for myasthenia crisis or for situations in which corticosteroid therapy should be discontinued. There is no decrease in sensation with MG, and muscle atrophy does not occur because muscles are used during part of the day.

What is the sign of mal-union?

persistent discomfort with moving (broken bones should not be moving under the cast)

A client with epilepsy is having a seizure. During the active seizure phase, the nurse should:

place the client on his side, remove dangerous objects, and protect his head.

Food high in calcium include what

plain yougurt, diary products, seafood, sardines, green vegetables, calcium-fortified orange juics, and cereal

Why is limb shaping important post amputation?

prosthesis -you want the end to be shaped like a cone (smaller and rounded at the bottom)

A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension tractions is primarily:

provides comfort by reducing muscle spasms and provides fracture immobilization

When evaluating a patient with trigeminal neuralgia who has had a glycerol rhizotomy, the nurse will ______________

question the patient about social activities with family and friends. rational: Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, asking about social activities will help in evaluating whether the patient's symptoms have improved. Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do facial exercises, or take precautions with chewing.

A patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse to the patient's behavior is to _______________

respect the patient's desire and arrange for privacy at mealtimes. rational: The patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements will reduce the patient's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient's embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.

The nurse is teaching a client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to:

rest in a room set at a comfortable temperature.

A client with diabetes mellitus has had a R BKA (right below knee amputation). The nurse should monitor for what?

separtion of wound edges. Client's with diabetes mellitus are more prone to wound infection and delayed healing because of the disease

A nurse is evaluating the pin sites of a client in skeletal traction. THe nurse is least concerned with 1. inflammation 2.serous drainage 3.pain at pin site 4.purulent drainage

serous drainage. A small amount of serous oozing is expected at pin insertion sites.

What is a gallium scan

similar to a bone scan, but with an injection of gallium isotope instead of technetium-99m. Gallium is injected 2-3 hours before the procedure, which takes 30-60 minutes to perform. The client must lie still during procedure and there is no special aftercare

For the patient in Buck's extension traction which is applied to a leg, the nurse can provide counteraction by:

slighltly elevating the foot of the bed

Bivalving a cast involves what

splitting the cast along both sides to allow space for swelling, facilitate taking x rays, or make a half cast usae as intermittent splint

To encourage adequate nutritional intake for a client with Alzheimer's disease, the nurse should:

stay with the client and encourage him to eat.

What to do with open fractures

sterile-dressing covering

A client has slight weakness in the right leg. Based on this information, teh nurse determines that the client would benifit most from the use of a

straight-leg cane is useful for the client with slight weakness in one leg

A client who is learning to use a can if afraid it will slip with ambulations causing a fall. the nurse provides the client with the greatest reassurance by telling the client that:

the cane has a flared tip with concentric rings to provide stability

A client with right sided weakness needs to learn how to use a cane. The nurse plans to teach the client to position the can by holding it with the

the client is taught to hold the cane on the opposite side of the weakness. This will be the patient's left hand. The cane is placed 6 inches lateral to the fithe toe

A nurse is evaluating the client's use of a cane for left sided weakness. The nurse would interven if the client moves the cane with witch side as the right leg is moved?

the nurse would interven and correct if the patient moves the cane when the righ leg is moved. The cane is held 6 inches lateral to the fifth great tow. The cane is moved forward with the affected leg. The client leans on the cane for added support while the stronger side swings through

A nurse is planning to teach the client with a left arm cast about measures to keep the left shoulder from becoming stiff. Which suggestion would the nurse include in the teaching plan

the shoulder of a casted arm should be lifeted over the head perodically as a prevenetive meausre.

The physician suspects myasthenia gravis in a client with chronic fatigue, muscle weakness, and ptosis. Myasthenia gravis is associated with:

thymus gland hyperplasia.

A client has a history of painful, continuous muscle spasms. He has taken several skeletal muscle relaxants without experiencing relief. His physician prescribes diazepam (Valium), 2 mg by mouth twice daily. In addition to being used to relieve painful muscle spasms, diazepam also is recommended for:

treatment of spasticity associated with spinal cord lesions.

When assessing a patient with newly diagnosed trigeminal neuralgia, the nurse will ask the patient about _______________

triggers that lead to facial pain. rational: The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia.

When communicating with a client who has sensory (receptive) aphasia, the nurse should:

use short, simple sentences.

A 78-year-old Alzheimer's client is being treated for malnutrition and dehydration. The nurse decides to place him closer to the nurses' station because of his tendency to:

wander.

(Select all that apply) A bone graft may be used for which of the following reasons? Select all that apply. a) Improvement of motion b) Defect filling c) Stimulation of bone healing d) Joint stabilization e) Reduction of a fracture

• Joint stabilization • Defect filling • Stimulation of bone healing Explanation: A bone graft is used for joint stabilization, defect filling, or stimulation of bone healing. Tendon transfer is used for improving motion. Either closed or open reduction may be used to reduce a fracture.