NUR 317 Exam 5 - ATI

A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. What following intervention is the nurse's priority?

Monitor pulse oximetry findings

A nurse is reviewing postoperative instructions with a client following cataract surgery. What client statement indicates an understanding of the instructions?

"I should call my doctor if my vision gets worse."

A nurse is teaching a client who has Parkinson's disease and is prescribed carbidopa-levodopa. What following client statement indicates an understanding of the teaching?

"I should expect that this medication can cause me to be drowsy."

A nurse is teaching a client who has multiple sclerosis and has a new prescription for glatiramer acetate. What statement indicates that the client understand the teaching?

"I will avoid going to the store when its crowded."

A nurse is developing a teaching plan for a client who has Ménière's disease. What instruction should the nurse include?

"Move your head slowly to decrease vertigo."

A nurse is teaching a client who has osteoporosis and has a new prescription for alendronate. What information should the nurse include in the teaching?

"Remain upright for 30 mins after taking this medication."

A nurse is teaching a client and her family about the diagnosis and treatment of Alzheimer's disease. What statement should the nurse identify as an indication that the family understands the teaching?

"The medications that treat Alzheimer's disease can help delay cognitive changes."

A nurse is caring for a client who has viral meningitis. What action should the nurse take?

Check capillary refill at least every 4 hr

A nurse is planning care for a client who has a closed traumatic brain injury from a fall and is receiving mechanical ventilation. What intervention is the nurse's priority?

Maintain a PaCO2 of approximately 35 mm Hg

A nurse is caring for a client who is in balanced suspension skeletal traction and reports intermittent muscle spasms. What action should the nurse take first?

Check the position of the weights and ropes

A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. What assessment finding should the nurse report to the provider?

Clear drainage from the nose

A nurse is performing a pain assessment for a client who is postoperative. What findings should the nurse use to determine the severity of the client's pain?

Client's report of pain on a pain scale

A nurse is assessing a client who has a new diagnosis of osteoarthritis. What findings should the nurse expect?

Crepitus with joint movement, decreased range of motion of the affected joint, and joint pain that resolves with rest

A nurse is planning care for a client following a lumbar puncture. What action should the nurse plan to take?

Ensure that the client lies flat for up to 12 hr

A nurse is caring for a client who has a history of status epileptics and requires seizure precautions. What action should the nurse take?

Establish IV access

A nurse is caring for a client who has a retinal detachment. What finding should the nurse expect?

Flashes of bright light

A nurse is assessing a client who has a right hemispheric stroke. What neurologic deficits should the nurse expect?

Impulsive behavior

A nurse is assessing a client who is quadriplegic following a cervical fracture at vertebral level C5. The client reports a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/110 mm HG. What action should the nurse take first?

Elevate the head of the client's bed

A nurse is caring for a client who has multiple sclerosis. What finding should the nurse expect?

Intention tremors

A nurse in an ED is assessing a client who reports sudden, severe eye pain with blurry vision. The provider determines that the client has primary angle-closure glaucoma. What medication should the nurse expect to administer?

Osmotic diuretics via IV bolus

A nurse is teaching an assistive personal about providing care to a client following a total hip arthroplasty. What instruction should the nurse include?

Place an abductor pillow between the client's legs when turning the client

A nurse is caring for a client who is recovering from a stroke and has right-sided homonymous hemianopsia. To help the client adapt to the hemianopsia, the nurse should take what action?

Remind the client to look consciously at both sides of their meal tray

A nurse is caring for a client who is 72 hr postoperative following an above-the-knee amputation and reports phantom limb pain. What following action should the nurse take?

Request a prescription for gabapentin for the client

A nurse is assessing a client who has a head injury following a MVA. The nurse should identify that what finding indicates increasing intracranial pressure?

Restlessness

A nurse is caring for a client who has a spastic bladder following a spinal cord injury. What action should the nurse take to help stimulation micturition?

Stroke the client's inner thigh

A nurse is planning to teach a client who has epilepsy and a new prescription for phenytoin. What following instructions should the nurse plan to include?

Take medication at a consistent time each day to have consistent therapeutic blood levels

A nurse in an ED is caring for a client who has sustained a fracture of the femur following a MVA. What image should the nurse recognise as a comminuted fracture?

The injury causes the bone to fragment into several pieces

A nurse is providing teaching for a client who is postoperative following a right hip arthroplasty. What image indicates the position the nurse should teach the client to take when sitting in a chair?

The nurse should teach the client to sit with the hips at a 90 degree angle or less with the knees slightly lower than the hips to avoid hip dislocation

A nurse in an ED is caring for a client who suddenly lost consciousness and fell while at home. The provider determines that the client had an embolic stroke. What medication should the nurse expect to administer?

Tissue plasminogen activator

A nurse is assessing a client who has rheumatoid arthritis. What finding should the nurse expect?

Ulnar deviation