Other Crap

Home nurse monitors pediatric client with chronic seizure disorder. Nurse should intervene if which of the following is observed? 1. Parent takes kids temp with oral thermometer 2. parent encourages child to play with boats in the bath 3. Child wears a helmet when riding a bike 4. child eats a PB&J

1

Nurse finds client having a tonic-clonic seizure in bed. What should the nurse do first? 1. loose constrictive clothing 2. restrain the client 3. position the client on the side 4. pad the bed's side rails

1

Nurse monitors client with myasthenis gravis. Which symptom alerts the nurse to potential onset of a myasthenic crisis? 1. difficulty speaking 2. hypotension 3. nausea and vomiting 4. sweating

1

Which finding does the nurse expect to see when assessing client diagnosed with Parkinson's 1. shuffling, propulsive gait 2. heat thrust forward, chin nutting out 3. hyperactive DTRs 4. hyperkinesia

1

Which intervention is most beneficial to the client diagnosed with MS who is experience diplopia? 1. patch one eye 2. limit oral intake 3. restrict ambulation 4. institute intermittent catheterization program

1

Which clinical manifestation should nurse anticipate for client with hx of MS 1. Urinary retention 2. Decrease in LOC 3. hyperreflexia of extremities 4. intestial obstruction 5. Ataxia 6. Decreased concentration

1, 3, 5, 6

During acute bout of gouty arthritis, expect the patient's affected foot to appear: 1. pale 2. red 3. mottled 4. cyanotic

2

Nurse cares for patient with seizure disorder. Patient tells nurse, "I smelled oranges today and there wasn't one on my tray." Which one of the following is the best response by the nurse? 1. You were probably craving an orange, I'll get you one from the kitchen 2. Have you experienced this sensation before? 3. Why do you think you're thinking about oranges

2

Client is diagnosed with ALS one month ago. Client discusses progress of disease with nurse, suddenly shouts, "leave me alone, I cannot talk about this with you anymore." Which is the nurse's most accurate interpretation of the client's behavior? 1. Client is embarrassed by symptoms 2. has interpersonal conflict wiht the nurse 3. in the anger phase of a grief reaction 4. needs to deal with the disease privately

3

Client has exacerbation of MS. What does the nurse expect to observe? 1. bradycardia and decreased BP 2. Ascending paralysis of skeletal muscles 3. enlarged pupils and facial paralysis 4. numbness of extremities and difficulty walking

4

The nurse is caring for a patient admitted to the nursing unit with osteomyelitis of the tibia. Which symptom will the nurse most likely find on physical examination of the patient? Nausea and vomiting Localized pain and warmth Paresthesia in the affected extremity Generalized bone pain throughout the leg

B

What signs is most suggestive of guillain-Barre syndrome?

ascending paralysis

A 50-year-old male patient has been diagnosed with amyotrophic lateral sclerosis (ALS). What nursing intervention is most important to help prevent a common cause of death for patients with ALS? Reduce fat intake. Reduce the risk of aspiration. Decrease injury related to falls. Decrease pain secondary to muscle weakness.

b

The nurse is admitting a patient who complains of a new onset of lower back pain. To differentiate between the pain of a lumbar herniated disc and lower back pain from other causes, what would be the best question for the nurse to ask the patient? "Is the pain worse in the morning or in the evening?" "Is the pain sharp or stabbing or burning or aching?" "Does the pain radiate down the buttock or into the leg?" "Is the pain totally relieved by analgesics, such as acetaminophen (Tylenol)?"

c

Which nursing diagnosis is likely to be a priority in the care of a patient with myasthenia gravis (MG)? Acute confusion Bowel incontinence Activity intolerance Disturbed sleep pattern

c

Classic signs of Parkinson's

tremor, bradykinesia, rigidity

Nurse enters room of a client admitted for evaluation of convulsive disorder. Family members present report the client had a seizure. After determining VS are normal, there are no injuries, and placing the client in side-lying position, which action is next? 1. Interview the family about what they observed and accurately document their response using their own words 2. explore family's feelings 3. document that the family witnessed a seizure, but the nurse did not, and record VS 4. Instruct family to call nurse the next time, complete an IR, notify provider

1

During the nursing history, admitting nurse attempts to ID the aura of a client diagnosed with grand mal seizures. Which of the following is accurate? 1. State of consciousness during seizure 2. unusual sensations prior to seizure 3. emotional status of patient after seizure 4. uncomfortable feeling as the seizure begins to subside

2

Nurse cares for client with 10 year history of osteoarthritis. What assessment is expected? 1. upper and lower extremity joints warm to touch and reddened in appearance 2. increased joint pain and stiffness after periods of activity 3. weight loss and decreased appetite 4. increased erythrocyte sedimentation rate (ESR)

2

Nurse cares for patient with MS experiencing motor weakness. Which action should be included in plan of care to promote optimal mobility? 1. allow client to walk independently 2. support the client when ambulating 3. allow client to maintain bed rest until weakness subsides 4. encourage hourly ambulation while client is awake

2

Nurse suspects the client is diagnosed with myasthenia gravis is experiencing a myasthenic crisis. Nurse bases this conclusion on which observation 1. Client is confused but awake and alert 2. the increased dose of anticholinesterase meds decreased symptoms 3. client had 5 loose stools within 24 hours 4. client has intermittent fasciculications in both arms

2

Prednisone is prescribed for a client with RA. What important points should the nurse include in teaching? 1. Provider will increase dose until there is a complete relief of symptoms 2. Dosage must be increased and decreased gradually 3. Some people experience incontinence as side effect of this medication 4. Prednisone is a dangerous medication and must be carefully monitored

2

What is it most important to schedule personal care for a patient with myasthenia gravis? 1. bedtime 2. morning 3. between 2-4pm 4. after evening meds

2

What action will prevent injuries related to sensory problems for client with MS? 1. use low setting when using a heating pad 2. Bathe the client in hot water 3. Inspect client's body parts frequently for injury 4. infrequently changing the client's position

3

When teaching correct body mechanics to an UAP, which of the following suggestions is most important? 1. bed at waist when lifting objects 2. lift objects with arms extended 3. bend knees when lifting objects 4. lean forward when lifting objects

3

Which intervention might the nurse include in the plan for a client diagnosed with Myasthenia gravis? 1. Med doses should not be altered 2. reduce outside stimulation 3. schedule activities in the morning 4. encourage use of sedatives to promote rest

3

Which is the highest priority nursing action to include in the plan of care for the client diagnosed with myasthenia gravis? 1. provide a liquid diet 2. encourage frequent activity, including ambulation 3. Teach CDB 4. obtain social service consult

3

Client has absence seizures. Most important for nurse to take which of the following actions 1. place the client on bedrest 2. pad the side rails 3. observe for autonomic, purposeless motions with intense emotional experiences 4. monitor for brief interruption of consciousness

4

Nurse assesses a patient with OA. What observation is expected? 1. pain on abduction of hips, waddling gait 2. fever, rash, and nodules over body prominences 3. swollen, reddened painful join with limitation of motion 4. stiffness of hips, knees, vertebrate, and fingers

4

Nurse cares for child experiencing seizure activity. Nurse should intervene if which is observed? 1. Side rails are raised on child's bed 2. there is suction at the child's bedside 3. There is a oxygen set-up at bedside 4. padded tongue blade is placed on child's bedside table

4

Provider orders progressive ambulation for the client diagnosed with an injury to lower back. Client has been on bed rest. Which should the nurse do when assisting the client in getting out of bed for the first time?

Dangle the client at the side of the bed before the client stands up

A 54-year-old patient with acute osteomyelitis asks the nurse how this problem will be treated. Which response by the nurse is most appropriate? "IV antibiotics are usually required for several weeks." "Oral antibiotics are often required for several months." "Surgery is almost always necessary to remove the dead tissue that is likely to be present." "Drainage of the foot and instillation of antibiotics into the affected area is the usual therapy."

a

The nurse is admitting a patient to the nursing unit with a history of a herniated lumbar disc and low back pain. In completing a more thorough pain assessment, the nurse should ask the patient if which action aggravates the pain? Bending or lifting Application of warm moist heat Sleeping in a side-lying position Sitting in a fully extended recliner

a

The patient with type 1 diabetes mellitus with hypoglycemia is having a seizure. Which medication should the nurse anticipate administering to stop the seizure? IV dextrose solution IV diazepam (Valium) IV phenytoin (Dilantin) Oral carbamazepine (Tegretol)

a

Which measure should the nurse prioritize when providing care for a patient with a diagnosis of multiple sclerosis (MS)? Vigilant infection control and adherence to standard precautions Careful monitoring of neurologic assessment and frequent reorientation Maintenance of a calorie count and hourly assessment of intake and output Assessment of blood pressure and monitoring for signs of orthostatic hypotension

a

Which nursing intervention is most appropriate when turning a patient following spinal surgery? Placing a pillow between the patient's legs and turning the body as a unit Having the patient turn to the side by grasping the side rails to help turn over Elevating the head of bed 30 degrees and having the patient extend the legs while turning Turning the patient's head and shoulders and then the hips, keeping the patient's body centered in the bed

a

A patient has been receiving scheduled doses of phenytoin (Dilantin) and begins to experience diplopia. The nurse immediately assesses the patient for an aura or focal seizure. nystagmus or confusion. abdominal pain or cramping. irregular pulse or palpitations.

b

The nurse identifies a nursing diagnosis of pain related to muscle spasms for a 45-year-old patient who has low back pain from a herniated lumbar disc. What would be an appropriate nursing intervention to treat this problem? Provide gentle ROM to the lower extremities. Elevate the head of the bed 20 degrees and flex the knees. Place the bed in reverse Trendelenburg with the feet firmly against the footboard. Place a small pillow under the patient's upper back to gently flex the lumbar spine.

b

The nurse is planning health promotion teaching for a 45-year-old patient with asthma, low back pain from herniated lumbar disc, and schizophrenia. What does the nurse determine would be the best exercise to include in an individualized exercise plan for the patient? Yoga Walking Calisthenics Weight lifting

b

Which characteristic of a patient's recent seizure is consistent with a focal seizure? The patient lost consciousness during the seizure. The seizure involved lip smacking and repetitive movements. The patient fell to the ground and became stiff for 20 seconds. The etiology of the seizure involved both sides of the patient's brain.

b

A female patient complains of a throbbing headache. When her history is obtained, the nurse discovers that the patient has had this type of headache before and experienced photophobia before the headache occurred. The nurse should know that what is probably the cause of this patient's headache? Polycythemia vera A cluster headache A migraine headache A hemorrhagic stroke

c

A male patient with a diagnosis of Parkinson's disease (PD) has been admitted recently to a long-term care facility. Which action should the health care team take in order to promote adequate nutrition for this patient? Provide multivitamins with each meal. Provide a diet that is low in complex carbohydrates and high in protein. Provide small, frequent meals throughout the day that are easy to chew and swallow Provide the patient with a minced or pureed diet that is high in potassium and low in sodium.

c

The nurse has reviewed proper body mechanics with a patient with a history of low back pain caused by a herniated lumbar disc. Which statement made by the patient indicates a need for further teaching? "I should sleep on my side or back with my hips and knees bent." "I should exercise at least 15 minutes every morning and evening." "I should pick up items by leaning forward without bending my knees." "I should try to keep one foot on a stool whenever I have to stand for a period of time."

c

A 67-year-old patient hospitalized with osteomyelitis has an order for bed rest with bathroom privileges with the affected foot elevated on two pillows. The nurse would place highest priority on which intervention? Ambulate the patient to the bathroom every 2 hours. Ask the patient about preferred activities to relieve boredom. Allow the patient to dangle legs at the bedside every 2 to 4 hours. Perform frequent position changes and range-of-motion exercises.

d

What is the most serious complication of Guillian Barre syndrome?

respiratory failure