Perception and coordination module 2 to 11
Which of the following interventions would be least appropriate for a client who is in a double hip spica cast?. a. Encouraging the intake of cranberry juice. b. Advising the client to eat large amounts of cheese. c. Having the client dangle at the bedside. d. Establishing regular times for elimination.
Advising the client to eat large amounts of cheese.
When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing intervention is contraindicated? a. Asking the client to speak louder when tired. b. Encouraging the client to speak slowly. c. Encouraging the client to speak distinctly. d. Asking the client to repeat indistinguishable words.
Asking the client to speak louder when tired.
The risk for injury during an attack of Ménière's disease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo? a. "Close your eyes tightly." b. "Assume a reclining or flat position." c. "Place your head between your knees." d. "Concentrate on rhythmic deep breathing."
Assume a reclining or flat position."
The nurse has been assigned to a client who is hearing impaired and reads speech. Which of the following strategies should the nurse incorporate when communicating with the client? Check all that apply. a. Talking to the client while doing other nursing procedures. b. Avoiding being silhouetted against strong light. c. Not blocking out the person's view of the speaker's mouth. d. Facing the client when talking. e. Having bright light behind so the individual can see. f. Ensuring the client is familiar with the subject material before discussing.
Avoiding being silhouetted against strong light., Not blocking out the person's view of the speaker's mouth., Facing the client when talking., Ensuring the client is familiar with the subject material before discussing.
A physician prescribes a lengthy x-ray examination for a client with osteoarthritis. Which of the following actions by the nurse would demonstrate client advocacy?. a. Contact the physician to determine if an alternative examination b. Contact the x-ray department and ask the technician if the lengthy session can be divided into shorter sessions. c. could be scheduled. d. Cancel the examination because of the hard x-ray table. e. Provide a dose of acetaminophen (Tylenol).
Contact the x-ray department and ask the technician if the lengthy session can be divided into shorter sessions.
Which of the following statements indicates the client understands the expected course of Ménière's disease? a. "Control of the episodes is usually possible, but a cure is not yet available." b. "The disease process will gradually extend to the eyes." c. "Bilateral deafness is an inevitable outcome of the disease." d. "Continued medication therapy will cure the disease."
Control of the episodes is usually possible, but a cure is not yet available."
Which of the following activities should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)? a. Passive range-of-motion (ROM) exercises. b. Coughing. c. Deep breathing. d. Turning.
Coughing
Sensorineural hearing loss results from which of the following conditions? a. Sclerosis of the bones of the middle ear. b. Presence of fluid and cerumen in the external canal. c. Damage to the cochlear or vestibulocochlear nerve. d. Emotional disturbance resulting in a functional hearing loss.
Damage to the cochlear or vestibulocochlear nerve.
A client with a fracture develops compartment syndrome. Which of the following signs should alert the nurse to impending organ failure?. a. Generalized edema. b. Crackles. c. Jaundice. d. Dark, scanty urine.
Dark, scanty urine.
The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider about which of the following changes in the client's condition? a. Muscle twitching b. Widening pulse pressure. c. Dilated, fixed pupils. d. Decrease in level of consciousness (LOC).
Decrease in level of consciousness (LOC).
Parkinson's disease has multiple etiologic factors. Destruction of the basal nuclei results to impaired secretion of which of the following neurotransmitter? a. Norepinephrine b. GABA c. Dopamine d. Acetylcholine
Dopamine
The nurse is planning care for a client with osteomyelitis. The client is taking an antibiotic, but the infection has not resolved. The nurse should advise the client to do which of the following?. a. Ask the health care provider for a change of antibiotics. b. Use herbal supplements. c. Eat a diet high in protein and vitamins C and D. d. Encourage frequent passive range of motion to the affected extremity.
Eat a diet high in protein and vitamins C and D.
In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client? a. Keeping the neck in a neutral position b. Keeping the client flat on one side or the other. c. Elevating the head of the bed to 30 degrees. d. Logrolling or turning as a unit
Elevating the head of the bed to 30 degrees.
Which of the following nursing interventions is appropriate for a client with an increased intracranial pressure (ICP) of 20 mm Hg? a. Administer low-dose barbiturates. b. Give the client a warming blanket. c. Encourage the client to hyperventilate. d. Restrict fluids.
Encourage the client to hyperventilate.
Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence? a. Insert an indwelling urinary catheter. b. Limit fluid intake to 1,000 mL/day. c. Administer prophylactic antibiotics, as prescribed. d. Establish a regular voiding schedule.
Establish a regular voiding schedule.
An unconscious client with multiple injuries arrives in the emergency department. Which nursing intervention receives the highest priority? a. Replacing blood loss. b. Checking for a neck fracture. c. Stopping bleeding from open wounds. d. Establishing an airway.
Establishing an airway.
A client with osteoarthritis will undergo an arthrocentesis on a painful, edematous knee. Which of the following should be included in the nursing plan of care? Select all that apply. a. PAdminister preoperative medication 1 hour before surgery. b. PInstruct the client to immobilize the knee for 2 days after the surgery. c. Explain the procedure. d. Offer pain medication. e. Assess the site for bleeding.
Explain the procedure., Assess the site for bleeding., Offer pain medication.
What should the nurse do first when a client with a head injury begins to have clear drainage from the nose? a. Administer an antihistamine for postnasal drip. b. Tilt the head back. c. Compress the nares. d. Give the client tissues to collect the fluid.
Give the client tissues to collect the fluid.
A 75-year-old client who has been taking furosemide (Lasix) regularly for 4 months tells the nurse that he is having trouble hearing. Which of the following would be the nurse's best response to this statement? a. Schedule the client for audiometric testing and a hearing aid. b. Tell the client that because he is 75 years old, it is inevitable that his hearing should begin to deteriorate. c. Tell the client that the hearing loss is only temporary; when his system adjusts to the furosemide, his hearing will improve. d. Have the client immediately report the hearing loss to his physician.
Have the client immediately report the hearing loss to his physician.
A nurse is assessing a client from head and toe. Which of the following findings would support the diagnosis of osteoporosis?
Hyperlaxity of fingers Flat footed Blue scleral tissues
Which of the following statements indicates that the client with osteoarthritis understands the effects of capsaicin (Zostrix) cream?. a. "I always wash my hands right after I apply the cream." b. "I keep the cream in the cabinet above the stove in the kitchen." c. "After I apply the cream, I wrap my knee with an elastic bandage." d. "I also use the same cream when I get a cut or a burn."
I always wash my hands right after I apply the cream."
Which of the following client statements identifies a knowledge deficit about cast care?. a. "I can pull out cast padding to scratch inside the cast." b. "I'll exercise my joints above and below the cast." c. "I'll elevate the cast above my heart initially." d. I'll apply ice for 10 minutes to control edema for the first 24 hours."
I can pull out cast padding to scratch inside the cast."
A nurse may be alerted by the which of the following subjective complaint of a client who is suspected of having osteoporosis? a. My muscles get easily sored especially when walking about 8 meters b. I can see that my fingers are spreading without any difficulty c. I could feel that my knees are weak that is why I have sometimes uncoordinated body movements d. I feel my back is continuously aching that's why I'm here on bed since last week
I feel my back is continuously aching that's why I'm here on bed since last week
At which of the following times should the nurse instruct the client to take ibuprofen (Motrin), prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation?. a. On an empty stomach. b. On arising. c. At bedtime. d. Immediately after a meal.
Immediately after a meal.
Which of the following should be included in the teaching plan for a client with osteoporosis? Select all that apply. a. Choose good calcium sources, such as figs, broccoli, and almonds. b. Avoid the use of high-fat foods, such as avocados, salad dressings, and fried foods. c. Maintain a diet with adequate amounts of vitamin D, as found in fortified milk and cereals. d. Use alcohol in moderation because a moderate intake has no known e. negative effects. f. Try swimming as a good exercise to maintain bone mass.
Maintain a diet with adequate amounts of vitamin D, as found in fortified milk and cereals., Choose good calcium sources, such as figs, broccoli, and almonds., Use alcohol in moderation because a moderate intake has no known, Try swimming as a good exercise to maintain bone mass.
The nurse develops a teaching plan for a client newly diagnosed with Parkinson's disease. Which of the following topics that the nurse plans to discuss is the most important? a. Enhancing the immune system. b. Engaging in diversional activity. c. Maintaining a balanced nutritional diet. d. Maintaining a safe environment.
Maintaining a safe environment.
The nurse administers mannitol (Osmitrol) to the client with increased intracranial pressure. Which parameter requires close monitoring? a. Pupil dilation. b. Intake and output. c. Muscle relaxation. d. Widening of the pulse pressure.
Muscle relaxation.
The nurse should use which of the following solutions to remove cerumen from the client's ears? a. Sterile water. b. Antiseptic solution. c. Normal saline. d. Warm tap water.
Normal saline.
The nurse is documenting care of a client who is restrained in bed with bilateral wrist restraints because of severe pain developed in the closed fracture of the ulna. Following assessment of the restraints, the nurse's documentation should include which of the following? Select all that apply. a. Nutrition and hydration needs. b. Skin integrity. c. Need for medication. d. Capillary refill. e. Continued need for restraints.
Nutrition and hydration needs., Capillary refill., Continued need for restraints., Skin integrity.
A client is receiving multiple medications for treatment of Parkinson's disease. Which signs and symptoms should a nurse recognize as adverse effects of levodopa? a. Orthostatic hypotension and dry mouth b. Dystonia and akinesia c. Muscle rigidity and cardiac dysrhythmias d. Bradykinesia and agitation
Orthostatic hypotension and dry mouth
Which of the following clinical features primarily differentiate osteoporosis from osteomalacia? a. Osteomalacia is a deficiency in calcium while osteoporosis is lack of calcium in the diet b. Osteomalacia affects children while osteoporosis is common in adults c. Osteomalacia is "soft bone" while osteoporosis is "brittle bone" d. Both osteomalacia and osteoporosis share the same clinical features
Osteomalacia is "soft bone" while osteoporosis is "brittle bone"
The client with an open femoral fracture was discharged to the home and developed fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg. Which of the following reflects the best interpretation of these findings?. a. Urinary tract infection. b. Fat emboli. c. Osteomyelitis. d. Pulmonary emboli.
Osteomyelitis
The nurse is planning care for the client with a femoral fracture who is in balanced suspension traction. Which of the following would the nurse be least likely to include in the plan of care?. a. Elevation of the head of bed no more than 25 degrees. b. Checks for redness over the ischial tuberosity. c. Personal hygiene with a complete bed bath. d. Use of a fracture bedpan.
Personal hygiene with a complete bed bath.
A client who has been taking hydrocodone with acetaminophen at home for 6 weeks following a fractured tibia is admitted with a blood pressure of 80/50 mm Hg, a pulse rate of 115 bpm, and respirations of 8 breaths per minute and shallow. The nurse interprets these findings as indicating which of the following?. a. Expected common adverse effects of the hydrocodone. b. Possible habituating effect of the long-term drug use. c. Hypersensitivity reaction to the acetaminophen. d. Hemorrhage from gastrointestinal irritation associated with the pain medication.
Possible habituating effect of the long-term drug use.
Which of the following respiratory patterns indicates increasing intracranial pressure in the brain stem? a. Asymmetric chest excursion. b. Slow, irregular respirations. c. Rapid, shallow respirations. d. Nasal flaring.
Slow, irregular respirations.
Eardrops have been prescribed to be instilled in the adult client's left ear to soften cerumen. To position the client, the nurse must do which of the following? Check all that apply. a. Have the client lie on the left side. b. Gently pull the auricle up and back. c. Gently pull the ear lobe down and back. d. Straighten the client's eustachian tube. e. Chill the eardrops prior to administering.
Straighten the client's eustachian tube., Gently pull the auricle up and back.
The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? Check all that apply. a. Systolic blood pressure. b. Cerebral perfusion pressure. c. Level of pain. d. Breath sounds. e. Urine output.
Systolic blood pressure., Cerebral perfusion pressure.
A client with a fractured right femur has not had any immunizations since childhood. Which of the following biologic products should the nurse administer to provide the client with passive immunity for tetanus?. a. Tetanus toxoid. b. Tetanus vaccine. c. Tetanus antigen. d. Tetanus antitoxin.
Tetanus antitoxin.
When admitting a client with a fractured extremity, the nurse should first focus the assessment on which of the following?. a. The actual fracture site. b. The area proximal to the fracture. c. The opposite extremity for baseline comparison. d. The area distal to the fracture.
The area distal to the fracture.
The client in traction for a fractured femur is having difficulty managing self-care activities. Which of the following would indicate a successful outcome of a goal of promoting independence for this client?. a. The client accepts that self-care is not possible while in traction. b. The client assists as much as possible in care, demonstrating increased participation over time. c. The client allows the nurse to complete care in an efficient manner without interfering. d. The client allows the spouse to assume total responsibility for care.
The client assists as much as possible in care, demonstrating increased participation over time.
A client has vertigo. Which of the following goals would be most appropriate to prevent injury related to altered immobility and gait disturbances? Check all that apply. a. The client assumes safe position when dizzy. b. The client performs vestibular/balance exercises. c. The client experiences no falls. d. The client demonstrates family involvement. e. The client keeps head still when dizzy.
The client assumes safe position when dizzy., The client experiences no falls., The client performs vestibular/balance exercises., The client keeps head still when dizzy.
A client has had multiple sclerosis (MS) for 15 years and has received various drug therapies. What is the primary reason why the nurse has found it difficult to evaluate the effectiveness of the drugs that the client has used? a. The client requires multiple drugs simultaneously. b. The client endures long periods of exacerbation before the illness responds to a particular drug. c. The client experiences spontaneous remissions from time to time. d. The client exhibits intolerance to many drugs.
The client experiences spontaneous remissions from time to time.
A client has a leg immobilized in traction. Which of the following activities demonstrated by the client indicate that the client understands actions to take to prevent muscle atrophy?. a. The client rolls the affected leg away from the body's midline twice per day. b. The client adducts the affected leg every 2 hours. c. The client asks the nurse to add a 5-lb (2.3-kg) weight to the traction for 30 min/day. d. The client performs isometric exercises to the affected extremity three times per day.
The client performs isometric exercises to the affected extremity three times per day.
The nurse observes that when a client with Parkinson's disease unbuttons the shirt, the upper arm tremors disappear. Which statement best guides the nurse's analysis of this observation about the client's tremors? a. The tremors disappear when the client's attention is diverted by some activity. b. tremors are probably psychological and can be controlled at will. c. There is no explanation for the observation; it is a chance occurrence. d. The tremors sometimes disappear with purposeful and voluntary movements.
The tremors sometimes disappear with purposeful and voluntary movements.
Which goal is the most realistic for a client diagnosed with Parkinson's disease? a. To cure the disease. b. To stop progression of the disease. c. To maintain optimal body function. d. To begin preparations for terminal care.
To maintain optimal body function.
A client who is regaining consciousness after a laminectomy becomes restless and attempts to pull out the IV line. Which nursing intervention protects the client without increasing the intracranial pressure (ICP)? a. Tuck the arms and hands under the drawsheet. b. Wrap the hands in soft "mitten" restraints. c. Apply a wrist restraint to each arm. d. Place in a jacket restraint.
Wrap the hands in soft "mitten" restraints.
A client with a serious spinal cord injury regains consciousness after several days. Which of the following nursing statements is most appropriate as the client awakens? a. "Can you tell me your name and where you live?" b. "I'll bet you're a little confused right now." c. "You are in the hospital. You were in an accident and unconscious." d. "I'll get your family."
You are in the hospital. You were in an accident and unconscious."
A client with multiple sclerosis (MS) is receiving baclofen (Lioresal). The nurse determines that the drug is effective when it achieves which of the following? a. Reduces the urine bacterial count. b. Stimulates the client's appetite. c. Relieves muscular spasticity. d. Induces sleep.
Relieves muscular spasticity.
To approach a deaf client, the nurse should do which of the following first? a. Get the client's attention. b. Talk while walking into the room. c. Knock on the room's door loudly. d. Close and open the vertical blinds rapidly.
Get the client's attention.
After teaching a group of clients with osteoarthritis about using regular exercise, which of the following client statements indicates effective teaching?. a. "Joint swelling should determine when to stop exercising." b. "Exercising in the outdoors year-round promotes joint relaxation." c. "Exercise helps to drive synovial fluid through the cartilage." d. "Performing range-of-motion exercises will increase my joint mobility."
"Exercise helps to drive synovial fluid through the cartilage."
A client calls a clinic 2 weeks after beginning to use oral levodopa, stating that the medication has been ineffective in controlling the symptoms of Parkinson's disease. Which of the following nursing actions is the most appropriate? a. Review the correct procedure for taking the medication b. Ensure that the client is eating a diet high in protein and Vitamin B6 c. Contact the physician to change the dose of the medication d. Remind the client that it may take 1-2 months to note any effects of the medication
Remind the client that it may take 1-2 months to note any effects of the medication
Which of the following is not a typical clinical manifestation of multiple sclerosis (MS)? a. Weakness in the extremities. b. Sudden bursts of energy. c. Muscle tremors. d. Double vision.
Sudden bursts of energy.
The nurse is caring for an older adult male who had open reduction internal fixation (ORIF) of the right hip 24 hours ago. The client is now experiencing shortness of breath and reports having "tightness in my chest." The nurse reviews the recent lab results. The nurse should report which ofthe following lab results to the physician?. a. Hematocrit (Hct): 40% (0.4). b. Serum glucose: 120 mg/dL (6.7 mmol/L). c. Erythrocyte sedimentation rate (ESR): 22 mm/h. d. Troponin: 1.4 mcg/L (1.4 μg/L).
Troponin: 1.4 mcg/L (1.4 μg/L).
The right hand of a client with multiple sclerosis trembles severely whenever she attempts a voluntary action. She spills her coffee twice at lunch and cannot get the buttons of her dress fastened securely. Which is the best legal documentation in nurses' notes of the chart for this client assessment? a. "Has an intention tremor of the right hand." b. "Needs assistance with dressing and eating due to severe trembling and clumsiness." c. "Slight shaking of right-hand increases to severe tremor when client tries to button her clothes or drink from a cup." d. "Right-hand tremor worsens with purposeful acts."
"Slight shaking of right-hand increases to severe tremor when client tries to button her clothes or drink from a cup."
A client who had an incomplete spinal cord injury with increased intracranial pressure is to be discharged to a rehabilitation facility. Which of the following rehabilitation outcomes would be appropriate for the client? The client will: a. Be able to return to his construction job in 3 weeks. b. Be emotionally stable and display preinjury personality traits. c. Actively participate in the rehabilitation process as appropriate. d. Exhibit no further episodes of short-term memory loss.
Actively participate in the rehabilitation process as appropriate.
Which of the following indicates that a client with a fracture of the right femur may be developing a fat embolus?. a. Numbness in the right leg. b. Migraine-like headaches. c. Acute respiratory distress syndrome. d. Muscle spasms in the right thigh.
Acute respiratory distress syndrome.
Pharmacologic treatment of a client with osteoporosis is primarily directed to which of the following medications? a. NSAIDS b. Supplementation of Vitamin D and calcium including phosphorous c. Steroids d. Biophosphonates
Biophosphonates
Which of the following nursing interventions can be helpful to a client with osteoporosis? Select all that apply. a. Regular exercise with stretching, toning, and PROM b. Regular executive check up with bone scanning c. Adequate intake of calcium and Vitamin D3 in the diet d. Observe safety measures at home especially geriatric patients
Adequate intake of calcium and Vitamin D3 in the diet, Regular exercise with stretching, toning, and PROM, Observe safety measures at home especially geriatric patients
An older adult has hearing loss and a sensation of fullness in both ears. The nurse should examine the ears for which of the following? a. Accumulation of cerumen in the internal canal. b. External otitis. c. Accumulation of cerumen in the external canal. d. Exostosis.
Accumulation of cerumen in the external canal.
The nurse prepares a teaching plan for a client about crutch walking using a two-point gait pattern. Which of the following should the nurse include?. a. Advance both crutches together and then follow by lifting both lower extremities to the level of the crutches. b. Advance a crutch on one side and then advance the opposite foot; repeat on the opposite side. c. Advance both crutches together and then follow by lifting both lower extremities past the level of the crutches. d. Advance a crutch on one side and simultaneously advance and bear weight on the opposite foot; repeat on the opposite side.
Advance a crutch on one side and simultaneously advance and bear weight on the opposite foot; repeat on the opposite side.
The nurse should assess the client with Ménière's disease for the intended outcomes of which of the following medications that are commonly used to manage the disease? Check all that apply. a. Antiemetics. b. Nonsteroidal anti-inflammatory drugs (NSAIDs). c. Antipyretics. d. Antihistamines. e. Diuretics.
Antihistamines., Antiemetics., Diuretics.
When evaluating an arterial blood gas report from a client with a subdural hematoma who had surgery and is now on a ventilator, the nurse notes the PaCO2 is 35 mm Hg (4.7 kPa). The ventilator settings are: TV 400, respiration rate 24, FIO2 100%. What should the nurse do first? a. Position the client with the head of bed elevated. b. Continue to monitor the client. c. Ask the respiratory technician to decrease the respiration rate on the ventilator to 18. d. Inform the charge nurse of the results of the report.
Ask the respiratory technician to decrease the respiration rate on the ventilator to 18.
Which of the following should the nurse include in the discharge plan for a client with multiple sclerosis who has an impaired peripheral sensation? Check all that apply. a. Carefully test the temperature of bath water. b. Inspect the skin daily for injury or pressure points. c. Avoid hot water bottles and heating pads. d. Avoid kitchen activities because of the risk of injury. e. Wear warm clothing when outside in cold temperatures.
Carefully test the temperature of bath water., Avoid hot water bottles and heating pads., Inspect the skin daily for injury or pressure points., Wear warm clothing when outside in cold temperatures.
The client with a hearing aid does not seem to be able to hear the nurse. The nurse should do which of the following first? a. Irrigate the ear canal. b. Contact the client's audiologist. c. Check the hearing aid's placement. d. Cleanse the hearing aid ear mold in normal saline.
Check the hearing aid's placement.
The nurse should conduct a focused assessment with the client with multiple sclerosis for risk of which of the following? Check all that apply. a. Skin breakdown. b. Dehydration. c. Seizures. d. Falls. e. Fatigue.
Falls., Skin breakdown., Fatigue.
The client diagnosed with osteoarthritis states, "My friend takes steroid pills for her rheumatoid arthritis. Why don't I take steroids for my osteoarthritis?" Which of the following is the best explanation?. a. Oral corticosteroids can be used in osteoarthritis. b. Intra-articular corticosteroid injections are used to treat osteoarthritis. c. Rheumatoid arthritis and osteoarthritis are two similar diseases. d. A systemic effect is needed in osteoarthritis.
Intra-articular corticosteroid injections are used to treat osteoarthritis.
Which of the following should the nurse assess when completing the history and physical examination of a client diagnosed with osteoarthritis?. a. Weight loss. b. Osteoporosis. c. Local joint pain. d. Anemia.
Local joint pain.
The client with Ménière's disease is instructed to modify the diet. The nurse should explain which of the following most frequently recommended diet modification for Ménière's disease? a. Low fat. b. High protein. c. Low carbohydrate. d. Low sodium.
Low sodium.
A client has a tibial fracture that required casting. Approximately 5 hours later, the client has increasing pain distal to the left tibial fracture despite the morphine injection administered 30 minutes previously. Which of the following should be the nurse's next assessment?. a. Presence of a distal pulse. b. Vital sign changes. c. Pain with a pain rating scale. d. Potential for drug tolerance.
Presence of a distal pulse.
Which of the following is the priority for a client with a fractured femur who is in traction at this time?. a. Prevent effects of immobility while in traction. b. Adapt to inactivity from the impaired mobility. c. Choose appropriate diversional activities during the prolonged recovery. d. Develop skills to cope with prolonged immobility.
Prevent effects of immobility while in traction.
When caring for a client with myasthenia gravis, the nurse should assess the client for which of the following manifestations of cholinergic crisis? Check all that apply. a. Respiratory rate of 6 and irregular rhythm. b. Increased heart rate. Decreased secretions and saliva. c. Ptosis. d. abdominal cramps. e. Fasciculation.
Ptosis., Fasciculation., Respiratory rate of 6 and irregular rhythm.
A client with multiple sclerosis (MS) lives with her daughter and 3- year-old granddaughter. The daughter asks the nurse what she can do at home to help her mother. Which of the following measures would be most beneficial? a. Weekly visits by another person with MS. b. Regular exercise. c. Day care for the granddaughter. d. Psychotherapy.
Regular exercise.
The client with a fractured tibia has been taking methocarbamol (Robaxin). Which of the following indicate that the drug is having the intended effect?. a. Decrease in nervousness. b. Lack of infection. c. Relief of muscle spasms. d. Reduction in itching.
Relief of muscle spasms.
A postmenopausal client is scheduled for a bone-density scan. The nurse should instruct the client to do which of the following before the procedure? a. Remove all metal objects on the day of the scan. b. Ingest 600 mg of calcium gluconate by mouth for 2 weeks before the test. c. Report any significant pain to the physician at least 2 days before the test. d. Consume foods and beverages with a high content of calcium for 2 days before the test.
Remove all metal objects on the day of the scan.
A client returned from surgery with a debrided open tibial fracture and has a three-way drainage system. The nurse should first take which of the following action? a. Determine if the client has increased pain from exposed nerve endings. b. Review the results of culture and sensitivity testing of the wound. c. Look for the presence of a pressure dressing over the wound. d. Check the client's blood pressure for hypotension resulting from additional vessel bleeding.
Review the results of culture and sensitivity testing of the wound.
After teaching a client about myasthenia gravis, the nurse would judge that the client has formed a realistic concept of her health problem when she says that by taking her medication and adhering to which of the following plans? a. Her fatigue will be relieved, but she should expect occasional periods of muscle weakness. b. Her symptoms will be controlled, and eventually the disease will be cured. c. She will live longer, but ultimately the disease will cause her death. d. She should be able to control the disease and enjoy a healthy lifestyle.
She should be able to control the disease and enjoy a healthy lifestyle.
The nurse is assessing a client for movement after halo traction placement for a C8 fracture. The nurse should document which of the following? a. The client's hand-grasp strength is equal. b. The client's arm straightens out from a flexed position against resistance. c. The client's arm pulls up from a resting position against resistance. d. The client's shoulders shrug against downward pressure of the examiner's hands.
The client's hand-grasp strength is equal.
When developing a teaching plan for a client who is prescribed acetaminophen (Tylenol) for muscle pain, which information should the nurse expect to include? Select all that apply. a. The client should have the international normalized ratio (INR) checked regularly. b. Acetaminophen exerts a strong anti-inflammatory effect. c. The drug can be used if the person is allergic to aspirin. d. Acetaminophen does not affect platelet aggregation. e. This drug causes little or no gastric distress.
The drug can be used if the person is allergic to aspirin., Acetaminophen does not affect platelet aggregation., This drug causes little or no gastric distress.
The client has a sustained increased intracranial pressure (ICP) of 20 mm Hg. Which client position would be most appropriate? a. The head elevated on two pillows. b. Trendelenburg's position. c. The head of the bed elevated 30 to 45 degrees. d. Left Sims' position.
The head of the bed elevated 30 to 45 degrees.
At what time of day should the nurse encourage a client with Parkinson's disease to schedule the most demanding physical activities to minimize the effects of hypokinesia? a. Early in the morning, when the client's energy level is high. b. When family members will be available. c. To coincide with the peak action of drug therapy. d. Immediately after a rest period.
To coincide with the peak action of drug therapy.
Which pathologic process is well understood as it originates in the NMJ? a. Parkinson's disease b. Amyotrophic Lateral Sclerosis c. Myasthenia Gravis d. Multiple Sclerosis
Myasthenia Gravis
Which of the following is an initial sign of Parkinson's disease? a. Akinesia. b. Rigidity. c. Bradykinesia. d. Tremor.
Tremor
The best method to remove cerumen from a client's ear involves which of the following techniques?
Inserting a cotton-tipped applicator into the external canal.
The son of an older adult reports that his father just "stares off into space" more and more in the last several months, but then eagerly smiles and nods once the son can get his attention. The nurse should assess the client further for which of the following? a. Hearing loss. b. Depression. c. Dementia. d. Anger.
Hearing loss.
A nurse who is taking care of geriatric client at home may include which of the following measure in order to avoid accidental falls that may lead to fracture? Select all that apply. a. Install emergency alarm system that can be easily reached by the client b. Remove rugs and other obstacles at the flooring c. Ensure the flooring is non skid d. Install of hand bars at the toilet e. Ensure adequate lighting
Install of hand bars at the toilet, Ensure the flooring is non skid, Remove rugs and other obstacles at the flooring, Ensure adequate lighting
