T3 NCLEX PN Neuromusculoskeletal System
A client is admitted to the hospital for surgery for an extra capsular cataract extraction with an intraocular lens implantation. Which instruction is most important for the nurse to include in the teaching program regarding postoperative activities?
Avoid bending from the waist Bending increases intraocular pressure and must be avoided.
Which finding would be expected by a nurse reviewing a child's history and physical before repair of a ventricular septal defect?
Bilateral lung sounds with rales and rhonchi Defects that allow blood flow from the higher pressure left side of the heart to the lower pressure right side (left-to-right shunt) result in increased pulmonary blood flow and cause heart failure. A child with ventricular septal defect would exhibit bilateral lung sounds with rales and rhonchi. In a right-to-left shunt, desaturated blood moved from right to left. This causes desaturation in the left side of the heart and in the systemic circulation.
Which complication can occur if primary open-angle glaucoma (POAG) is left untreated?
Blindness
Which action would the nurse take to assess the neurovascular status of an extremity casted from the ankle to the thigh?
Compress and release the toenails of the affected foot.
What is the pain of a herniated nucleus pulposus caused by?
Compression of the spinal cord by the extruded nucleus pulposus Pain results because herniation of the nucleus pulposus into the spinal column irritates the spinal cord or the roots of spinal nerves.
Which would the nurse explain as being the chief aim of treatment for a client diagnosed with open-angle glaucoma?
Control the intraocular pressure
Which action would the nurse take when caring for a client who has a possible skull fracture?
Monitor the client for signs of brain injury
Which action is appropriate when caring for a client who has a tonic-clonic seizure caused by an overdose of aspirin?
Monitor vital signs every 15 minutes.
A client who sustained multiple injuries from a motor vehicle crash is oriented to person and place but is confused as to time. The client complains of a headache and drowsiness but assessment reveals that the pupils are equal and reactive. Which action would be taken by the nurse?
Monitoring the client for increasing intracranial pressure Limited increasing ICP and resulting brain damage depends on frequent, systematic assessments to identify this complication early.
A nurse is caring for a child in the pediatric intensive care unit who has increased intracranial pressure as a result of head trauma and has been prescribed intravenous mannitol. The nurse closely monitors the child's intracranial pressure and urine output, keeping in mind that mannitol belongs to which classification of diuretics?
Osmotic diuretics
Which condition occurs in part as a result of deficiencies in vitamin D and calcium?
Osteoporosis
Which manifestation is associated with osteoarthritis?
Pain and stiffness of the joints
A client's tibia is fractured in a motor vehicle accident, and a cast is applied. The nurse should assess for which manifestation indicating damage to major blood vessels caused by the fractured tibia?
Prolonged reperfusion of the toes after blanching
Which rationale would the nurse teach a client regarding the purpose of rigid bandaging of the residual limb after an amputation?
Promote shrinkage of the distal end of the residual limb
Which manifestation would a client with rheumatoid arthritis taking Meloxicam need to report to the health care provider?
Skin rash A client with rheumatoid arthritis who is on meloxicam needs to report the presence of a skin rash to the primary HCP.
When caring for a client newly diagnosed with myasthenia gravis, it is most important for the nurse to plan to do what?
Space activities throughout the day.
Impairment in which area would the nurse expect in a client with expressive aphasia?
Speaking or writing
Which function would be included by a nurse discussing impairment with the children of an older client who experiences a cerebrovascular accident (CVA) and has right-sided hemiplegia and expressive aphasia?
Stating wishes verbally
Which medication would the nurse consider may be related to difficulty in hearing in a client with a history of tuberculosis?
Streptomycin Ototoxicity is an adverse effect of aminoglycosides
Which clinical indicator is the nurse most likely to identify when assessing a client with a ruptured cerebral aneurysm?
Sudden severe headache Bleeding into the enclosed cavity of the skull creates pressure, causing pain. Seizures are not directly related to the hemorrhage; they result from abnormal electrical charges that may eventually develop as a consequence of tissue ischemia.
Which position would a nurse implement in a client who sustained a back injury after falling 20 ft (6 m)?
Supine position while not allowing the spine to flex
Which prescription eye drops does the nurse expect that the client with primary open-angle glaucoma will receive?
Timolol maleate Timolol maleate is a beta-adrenergic that decreases aqueous humor production and increases outflow, thereby reducing intraocular pressure.
Which reason explains the use of the Glasgow Coma Scale by the nurse performing an assessment of a traumatized client?
To assess level of consciousness
Which cranial nerve would a nurse suspect has been injured in a client who is unable to clench the teeth after a motor vehicle collision?
Trigemnial nerve The trigeminal nerve provides motor innervation to the muscles of the jaw and sensory innervation to the facial skin.
Which antiepileptic drug can cause photophobia?
Trimethadione
Which drug is commonly used for treating absence seizures?
Valproic acid
Which explanation by the nurse is appropriate for a client receiving phenytoin who asks why folic acid (folate) was prescribed?
"Absorption of folate from foods is inhibited." Phenytoin inhibits folic acid absorption and potentiates the effects of folic acid antagonists.
Which statement by the nurse to a client receiving phenytoin for a seizure disorder is appropriate?
"Anti seizure drugs will probably be continued for life."
Which explanation by the nurse would help the family member of an 80-year-old client with dementia to understand the aging process in relation to the client appearing thin and older?
"As we age, we lose the tissue that helps puff out the skin."
Which statement made by a coworker about the care to be taken in clients with neurologic changes associated with aging indicates that the nurse needs to intervene?
"Clients with decreased sensory perception of touch should be carefully monitored for infection."
Which statement regarding rheumatoid arthritis (RA) is true?
"It is a systemic condition."
Which explanation about anticoagulant therapy does the nurse give to a client with a hemorrhagic stroke?
"It is contraindicated because it will increase bleeding."
Which statement by the nurse best explains arthroscopic knee surgery?
"It is surgical repair of a joint under direct visualization using a device with a tiny video camera attached to it."
Which response would a nurse give to a client with multiple slerosis that is informed that it is a chronic progressive neurologic condition and asks, "Will I experience pain?"
"Pain is not always characteristic of this condition."
Which instruction would a nurse give to a client feeling faint and lightheaded when getting out of the bed for the first time since a discectomy and fusion for a herniated nucleus pulposus?
"Sit on the edge of the bed for us to hold you upright."
Which action would the nurse ask the client to perform when assessing for damage to the glossopharyngeal and vagus nerves (cranial nerves IX and X)?
"Swallow."
Which explanation would the nurse give the client about glaucoma?
"There is an increase in the pressure within the eyeball."
Which question is most useful when planning nursing care for a client who has a tonic-clonic seizure at work?
"Were you aware of anything different or unusual just before your seizure began?"
Which response by a nurse caring for an 80-year-old client with Alzheimer disease would be appropriate to a family member who remarks how thin and wrinkled the client has become?
"With aging we lose the tissue that helps puff out the skin."
Which sign is associated with generalized tonic-clonic seizures? SATA
(1,2,3) *Excessive salivation *Partial loss of vision *Loss of consciousness
Which part of the skeleton is categorized as axial? SATA
(1,2,3) *Skull *Sternum *Vertebrae
Which factor can contribute to reduced healing in a client with osteomyelitis? SATA
(1,3,5) *Diabetes *Smoking *Alcoholism
Which clinical finding supports the diagnosis of Parkinson disease? SATA
(1,3,5) *Nonintention tremors *Masklike facial expression *Low-pitched monotonous voice
Which hormone is involved in building and maintaining healthy bone tissue? SATA
(1,4) *Insulin *Growth hormone Insulin works together with growth hormone to increase bone length.
Which factor would the nurse include in a teaching session about the causes of stroke in young people? SATA
(ALL) *Drug abuse *Rheumatic fever *Atrial Fibrillation *Sickle cell anemia *Mitral valve prolapse *Smoking combined with oral contraceptive use
Which number represents that Glasgow Coma Scale of a client who opens eyes to pain, flexes to pain, and speaks inappropriate words?
8 The client who opens the eyes in response to pain score 2 points, flexes the extremities in response to pain scores 3 points, and answers with inapprorpriate words scores 3 points. This adds up to 8. A client scoring 8 points on the GCS after trauma requires medium priority.
Which instruction would a nurse give to a client who asks for assistance onto the bedpan on the first postoperative day after a total hip replacement?
Flex the knee on the unoperated leg and pull on the trapeze to life the pelvis.
Which function is associated with the biceps brachii muscle?
Flexion of the lower arm The biceps brachii muscle flexes the lower arm.
Which finding would the nurse expect when assessing a client with myasthenia gravis?
Fluctuating weakness of muscles innervated by the cranial nerves
Which element of nursing care would the nurse review with a client who is scheduled for a laminectomy?
Logrolling technique
Which assessment finding would the nurse anticipate for a client who has pen-angle (chronic) glaucoma?
Loss of peripheral vision
Which sleep promotion technique would the nurse advise for a client who complains about being unable to sleep well at night and then feeling sleepy throughout the next day?
Exercise daily
Which sign of hypokalemia would the nurse monitor for in a client who is taking furosemide?
Flabby muscles With hypokalemia, failure occurs in myoneural conduction and smooth muscle functioning, resulting in fatigue, muscle weakness, and soft, flabby muscles.
Which manifestation would a nurse expect when caring for a client with a tumor of the cerebellum?
Inability to execute coordinated movements
Which symptoms is the client who has a tumor of the cerebellum most likely to exhibit?
Inability to execute smooth movements
Which is the maximum length of time the nurse can allow an older adult with a cerebrovascular accident to remain in one position?
1-2 hours
Place in order the steps of healing that a bone goes through to repair a fracture.
1. Hematoma formation 2. Fibrocartilage formation 3. Callus formation 4. Ossification 5. Consolidation and remodeling
Damage to which cranial nerve may lead to a decrease in the client's olfactory acuity?
Cranial nerve I Cranial nerve I is the olfactory nerve and originates at the olfactory bulb and assists with the perception of smell. Damage to this nerve may cause a decrease in olfactory acuity.
Which symptom in the client indicates late-stage brain herniation?
Cushing response Cushing response is the condition in which there is widened pulse pressure, increased systolic blood pressure, irregular respirations, and bradycardia.
Which sign is a reliable indicator of increased intracranial pressure in a client admitted to the hospital after sustaining a head injury?
Decrease in the level of consciousness
Which goal of therapy would the nurse anticipate when administering allopurinol to a client with gout?
Decrease uric acid production
Which factor contributes to calcium loss in a client who has paraplegia?
Decreased activity
Which mechanism is responsible for the effectiveness of immunosuppressive therapy in a client with myasthenia gravis?
Decreases the production of autoantibodies that attack acetylcholine receptors
Which effect does the nurse consider therapeutic in a client treated with lorazepam for status epilepticus?
Depresses the central nervous system (CNS).
Which intravenous medication would the nurse anticipate being prescribed for a tonic-clonic seizure that involves all extremities?
Diazepam
The nurse evaluates that teaching about myasthenic and cholinergic crises is understood when a client with myasthenia gravis states that which characteristic is common to both crises?
Difficulty breathing
Which characteristic is common to both myasthenic and cholinergic crises?
Difficulty breathing
Which antiinfective agent may lead to blindness if not used correctly by the client in prescribed amounts?
Gentamicin
Which term would the nurse use to describe a flat, poorly defined mass on the sole over a bony prominence caused by pressure?
Callus A callus is described as a flat, poorly defined mass on the sole over a bony prominence that is caused by pressure.
Which technique would a nurse reinforce when teaching a client how to self-administer eye drops after cataract surgery?
Holding the dropper tip above the conjunctival sac
Which clinical manifestation of aspirin toxicity would the nurse teach the client who is taking large doses of aspirin?
Disturbances in hearing
When assisting a client who had a total hip replacement onto the bedpan on the first postoperative day, what would the nurse instruct the client to do?
"Flex the unaffected knee and pull on the trapeze to raise the pelvis."
Which statement made by a client with glaucoma indicates to the nurse a need to intervene? SATA
"I can lift objects that weigh more than 10 lb (4.5kg)." "I should keep my head in a dependent position."
Which statement by the nurse best describes the arthroscopy of the knee procedure?
"It is a direct visualization of the joint to diagnose the extent of your knee injury."
Which rationale explains why a nurse would avoid using the gluteus maximus muscle for administration of intramuscular medications in a client with gluteal edema?
Blood supply is insufficient for adequate absorption.
Which action would a nurse take when assisting a client to get out of bed after hip replacement surgery?
Advise the client that the legs must continually be kept wide apart.
Which intervention would the nurse implement for a client with a spinal cord injury who has difficulty voiding and an indwelling catheter?
Assess urine for cloudiness and foul odor.
Which action by the nurse is essential when caring for a client after spinal surgery?
Assessing the client's feet for circulation and sensation
Which action would be the nurse's priority while providing postprocedure care to a client after an arthroscopy?
Assessing the neurovascular status of the client's affected limb
Which medical emergency would the nurse continually monitor for in a client who sustained a transection of the spinal cord?
Autonomic hyperreflexia
Which outcome would the nurse explain to a client with primary angle-closure glaucoma is a desired effect of therapy?
Controlling intraocular pressure Glaucoma is a disease in which there is increased intraocular pressure. Narrow of the aqueous outflow channel (canal of Schlemm) causes primary angle-closure glaucoma. This can lead to blindness caused by compression of the nutritive blood vessels supplying the rods and cones.
Which type of equipment is a Buck extension to immobilize a fracture?
Cutaneous traction A buck extension is an example of a traction applied directly to the skin (cutaneous) by tape or by a foam boot.
Which medication may be used to improve the sleep pattern of a client with fibromyalgia syndrome?
Cyclobenzaprine Cyclobenzaprine may be used to improve the sleep pattern of a client with fibromyalgia syndrome.
Which method would the nurse use to open the airway of a client who is suspected of sustaining a spinal cord injury?
Jaw-thrust method
Which term would a nurse use to document difficulty in communicating by writing observed in a client with Alzheimer disease?
Dysgraphia
Which test result will be elevated in a client with inflammatory arthritis?
Erythrocyte sedimentation rate (ESR)
Which action would the nurse perform while the dosage of pyridostigmine tablets is being adjusted for a client with myasthenia gravis?
Evaluate the client's muscle strength every hour after the medication is given. The onset of action of pyridostigmine is 30-45 minutes after administration, and the effects last up to 6 hours.
Which is an expected outcome for a client who is scheduled to begin a walking and exercise program after a painful exacerbation of rheumatoid arthritis?
Exercise and be active unless the discomfort becomes too great.
A nurse assesses a client's electronic medical record (EMR) and observes increased blood pressure, severe myopia, and increased blood glucose levels. Which type of eye disorder would the nurse expect to be written in the EMR?
Glaucoma The common causes for glaucoma are associated conditions such as diabetes mellitus, HTN, and severe myopia. Therefore, a client with these diseases is at a higher risk for glaucoma.
Which purpose of Buck traction would a nurse recall when caring for a client with an intertrochanteric fracture of the femur who is awaiting surgery?
Immobilizes the fracture A continuous pull on the lower extremity keeps bone fragments from moving and causing further trauma, pain, and edema. The fracture will be reduced by surgery, and Buck traction is a temporary measure before surgery.
Which is the primary reason that clients are fitted with a prosthesis soon after amputation of a limb?
Improving the client's physical abilities
Which explanation does the nurse give for the increased risk for respiratory complications in clients with myasthenia gravis?
Ineffective coughing Weakened muscles result in ineffective coughing; secretions are retained and provide a medium for bacterial growth.
Which explanation does the nurse make for swollen finger joints in a client who is having an episode of rheumatoid arthritis?
Inflammation in the joint's synovial lining
Which condition may be anticipated in the client diagnosed with the genetic disorder osteogenesis imperfecta at the age of 30?
Loss of auditory acuity
Which mechanism of injury would a nurse suspect in a client with a direct injury to the vertebral column from a gunshot?
Penetrating trauma
Which action would a nurse take for a client who states, after surgery for a fractured hip, "I don't remember when I have ever been so uncomfortable"?
Perform a complete pain assessment
Which sign would be documented by the nurse assisting in a lumbar puncture who observes an increase in spinal fluid pressure when pressure is placed on the jugular vein?
Queckenstedt sign Pressure on the jugular vein causes increased ICP (Queckenstedt sign) when there is no obstruction. This, in turn, causes an increase in spinal fluid pressure.
A client with periods of confusion and disorientation is brought to the emergency department by family members after a fall at home. Which assessment tool is the best way for the nurse to determine whether this behavior is new for the client?
Question the family members about the client's usual behavior.
Which reason would the nurse give when a client with rheumatoid arthritis asks why it is necessary to inject hydrcortisone into the knee joint?
Reduces inflammation
A client who takes four 325-mg tablets of buffered aspirin four times a day for severe arthritis complains of dizziness and ringing in the ears. Which complication does the nurse conclude that the client probably is experiencing?
Salicylate toxicity
Which information would the nurse include in the discharge teaching plan of a client who has a cerebrovascular accident (CVA) with residual hemiparesis and hemianopsia?
Significance of a safe environment
When providing discharge teaching to a client who had a total hip replacement, what would the nurse instruct the client to avoid?
Sitting in a low chair
Which movement results in the palm facing upward or forward?
Supination Supination is a type of hand and forearm movement that facilitates the palm facing upward or forward.
Which diversional activity would the nurse encourage to meet the needs of a client with multiple sclerosis in remission?
Swimming
Which advice would a nurse give to a client with rheumatoid arthritis asking about ways to decrease morning stiffness?
Take a hot tub bath or shower in the morning
When preparing a client with a suspected brain tumor for a computed tomography (CT) scan, which intervention would the nurse expect to implement
Telling the client about what to expect during the examination
Which cerebral lobe includes the speech area that allows a client to process words into coherent thoughts?
Temporal Language comprehension.
Which definition best describes a comminuted fracture?
The bone has broken into several fragments, and the skin is intact. In a comminuted fracture, the bone is broken into several fragments or crushed.
Which reason explain why adequate nutritional intake would be a challenge for a client with bipolar disorder during the manic phase?
The client is too busy keeping active to eat.
Which information regarding using a cane is accurate?
The elbow should be flexed to approximately 30 degrees when using a cane.
Which conclusion would a nurse make when a client with myasthenia gravis develops loose stools and increased salivation 2 days after beginning to take the cholinesterase inhibitors pyridostigmine
These are cholinergic effects.
Which response is a component of the Glasgow Coma Scale (GCS)? SATA
(1,3,4) *Best verbal response *Best motor response *Best eye-opening response
The nurse assesses a 65-year-old client's electronic medical record and notices a history of increased lens density. Which nursing action would be appropriate for this client? SATA
(4,5) *Monitoring the client's blood glucose levels *Assessing if the client is under antiplatelet medication
Which condition may result in amputation of a lower extremity? SATA
(ALL) *Gangrene *Arteriosclerosis *Diabetes mellitus *Chronic osteomyelitis *Peripheral vascular disease (PVD)
Which statement about the basic principles of good sleep hygiene made by a client with fibromyalgia syndrome indicates that teaching has been effective? SATA
(1,4,5) I'll avoid long naps. I'll go to bed and wake up at the same time each day. I'll keep the sleep environment dark, quiet, and comfortable.
Which clinical manifestation is associated with increasing intracranial pressure (ICP) for a client with a brain injury? SATA
(2,5) *Widening pulse pressure *Bradycardia
Which statement indicates that a client in a halo fixation device and body cast for a cervical neck injury has had concerns about body image resolved successfully?
"I've gotten used to the brace. I may even miss it when it's gone."
Which response would the nurse give to the spouse of a client with an intracranial hemorrhage who asks, "Why aren't they administering an anticoagulant"?
"It is contraindicated because bleeding will increase."
A client admitted to the hospital with an acute episode of rheumatoid arthritis (RA) asks why physical therapy has not been prescribed. Which is the most appropriate nursing response?
"Your joints are still inflamed, and physical therapy can be harmful."
Which intervention would the nurse institute to keep a client with Guillain-Barre syndrome safe from injury? SATA
(ALL) *Inspect the skin. *Keep the bed in low position. *Use a moisture chamber for the eyes. *Raise side rails while the client is in bed. *Put call light within easy reach of the client.
Which goal of treatment would the nurse expect to see in the care plan of a client who experienced a fracture? SATA
(ALL) *Pain relief *Intact skin *Good tissue perfusion *Maintenance of mobility *Independence with activities of daily living (ADLs) *Prevention of complication
Which manifestation would the nurse including in a teaching session on Parkinson disease? SATA
(ALL) *Tremor *Monotone voice *Gait disturbances *Pill rolling behavior *Handwriting changes *Lack of facial expression
Which score in the Glasgow Coma Scale (GCS) is assigned when the client has no eye response after a head injury
1 A score of 1 is assigned when the client has no eye response. The score of 0 is never given in the GCS.
Which type of seizure occurs during childhood and adolescence and rarely continues after adolescence?
Absence Absence seizures occur during childhood and adolescence and rarely continue after adolescence.
Which medication would the nurse anticipate the health care provider to prescribe to relieve the pain experienced by a client with rheumatoid arthritis?
Acetylsalicylic acid
Which concern is the focus of a nurse caring for a client after an amputation who begins to experience extreme discomfort in the area where the limb once was?
Addressing the pain
Which action would the nurse take in a client being treated for clonic-tonic seizures whose phenytoin level is 16 mg/L?
Administer the next dose of the medication as prescribed.
Which action would a nurse take in a client who complains of feeling nauseated immediately after cataract surgery?
Administer the prescribed antiemetic.
Which description would the nurse provide to a client to help explain what a cataract is?
An opacity of the lens A cataract is a clouding over, or an opacity, of the crystalline lens or its capsule.
Which response would be given to a client with rheumatoid arthritis who asks the nurse "What kind of drug is acetylsalicylic acid?"?
Analgesic
Which instruction would the nurse include in the teaching plan of a client who had a laminectomy and is prescribed a back brace?
Apply the brace before getting out of bed
Which action of a client with ankylosing spondylitis would be beneficial in treatment?
Applying heat to the back and hips
Which prescription would the nurse anticipate will be prescribed by the health care provider for a client who is experiencing both tingling of the extremities and tetany?
Calcium supplements
Where does the nurse suspect a brain tumor is located when a client has loss of equilibrium and coordination?
Cerebellum
Which action would the nurse take as part of the focused assessment or monitor the neurologic status of a client after a lumbar laminectomy?
Check to see if the client can localize light touch sensation on the feet.
During a home visit, a nurse discovers that a child in the household has a disability and has been experiencing seizures. The child's parent is unresponsive to the child's physical, emotional, or medical needs and seems to provoke seizure episodes by harsh verbal exchanges with the child. Which referral would the nurse make to ensure intervention by the appropriate community resource?
Child Protective Services
Which intervention is useful in promoting comfort for the client experiencing a headache?
Cold therapy
Which test would be recommended in a client admitted to the hospital with a tentative diagnosis of a brain tumor?
Computed tomography Computed tomography is the most definitive test for identifying unexpected structures in the brain because it provides a 3-d view of cranial contents and defines outlines of masses and other abnormalities.
Which finding is most definitive in determining myasthenic crisis?
Difficulty breathing Excessive weakness and impaired diaphragmatic innervation result in difficulty breathing.
Which clinical finding is the nurse most likely to identify on a client who is diagnosed with myasthenia gravis?
Difficulty swallowing saliva
Which nursing assessment is the most significant for a client who is suspected of having myasthenia gravis?
Effectiveness of respiratory exchange and ability to swallow
Which action would be taken when arm weakness with sustained movement is observed in a client with myasthenia gravis while the nurse is assisting with a morning bath?
Encourage the client to rest for short periods
Which instruction would the nurse give to family members of a client with expressive aphasia who ask how they can help the client regain as much speech function as possible?
Encourage the client to speak while being patient with each attempt
Which lobe of the cerebrum includes the client's Broca area, which is responsible for speech?
Frontal
Which criterion would prevent a client experiencing a stroke from receiving treatment with tissue plasminogen activator (t-PA)?
Head trauma within the last 3 months Tissue plasminogen activator (t-PA) is given to dissolve clots in clients diagnosed with ischemic strokes.
The nurse documents the following information in the medical record of a 76-year-old client who underwent a total hip replacement (THR). After notifying the health care provider, which action would the nurse choose to implement next?
Hold physical therapy
Which medication used for treatment of rheumatoid arthritis has a delay in absorption when taken with food?
Ibuprofen
Which position would a nurse plan to maintain a client who has experienced a subarachnoid hemorrhage?
In bed with the head of the bed elevated
Which finding supports the nurse's conclusion of a positive Romberg test found during a neurological assessment?
Inability to stand with feet together when eyes are closed The Romberg test evaluates proprioception. A client is asked to close the eyes when standing. A positive Romberg test is documented if balance is lost after the client's eyes are closed and suggests that there is a sensory cause.
Which early indicator of potential damage to the motor branch of the facial nerve would the nurse assess for when caring for a client after surgery on the ear?
Inability to wrinkle the forehead
Which instruction would the nurse give the client who has a new prescription for hydrochlorothiazide?
Increase the intake of potassium.
Which clinical finding is most indicative of increasing intracranial pressure in a client with a severe head injury?
Increased restlessness
Which finding indicates tophi in a client whose external ear assessment revealed hard nodules on the pinna?
Increased uric acid levels in the blood
Which medication would the nurse expect the HCP to prescribe to relieve a client's physiological responses to Parkinson disease?
Levodopa
Which manifestation is associated with a cluster headache?
Ipsilateral tearing of the eye Ipsilateral tearing of the eye (same side as the headache) is a clinical manifestation of cluster headaches.
Which explanation would the nurse give to a client who asks if he or she can take acetaminophen for arthritis?
It lacks an anti-inflammatory action.
Which information would the nurse include about skin care when developing a teaching plan for a client with scleroderma?
Keep skin lubricated with lotion.
Which nursing action is most appropriate when caring for a client who is legally blind and is admitted to the hospital for surgery?
Keep the furniture in the same location in the room.
Which clinical finding would the nurse expect to find in the client who has been taking diuretics and is admitted to the hospital with hypokalemia?
Leg weakness and muscle cramps
Which is the priority nursing care for a client who had a cerebrovascular accident (brain attack) and is admitted to the hospital in a coma?
Maintain an open airway.
What is the most significant complication in a client who has a cast, for which the nurse would assess the client's extremity?
Numbness
Which action would a nurse take when planning care for a client on phenytoin for 10 years for seizures who is admitted with a partial occlusion of the left common carotid artery?
Obtain a history of seizure type and incidence
Which is the key factor that will affect how a client who just had an above-the-knee amputation will cope with the changes in body image?
Personal perception of the change
Which action would a nurse perform on a client's cast to prevent skin irritation?
Petaling Petaling a cast involves placing short pieces of tape over the rough edges of the cast to prevent skin irritation and to protect the cast from moisture and soiling.
Which statement regarding phantom limb pain is accurate?
Phantom pain is often described as a burning, stinging, or crushing pain in the amputated limb
Which referral would the nurse recommend to parents of a 7-year-old with juvenile idiopathic arthritis who are concerned about the lifelong effects of the disorder and are investigating other therapies to use with the medications?
Physical therapy
The nurse would assess the client with a compound fracture of the femur for which clinical indicator that is unique to a fat embolus?
Pinpoint red spots on the chest Fat emboli cause capillary fragility; rupture of capillary walls results in pinpoint red spots (petechiae).
Which intervention would the nurse implement to prevent contractures in a client who had a right below-the-knee amputation?
Place the client in a prone position 3 to 4 times daily
Which intervention would the nurse perform first in a client with a closed head injury sustained in a motor vehicle accident (MVA) whose assessment indicates increased intracranial pressure (ICP)?
Place the head and neck in alignment. The nurse should first attempt nursing interventions such as placing the head and neck in alignment (neutral position) to facilitate venous return and thereby decrease ICP.
A client with carpal tunnel syndrome reports increasingly difficulty holding the tools needed for woodworking. The client states, "I must return to work tomorrow. I can't get behind on my schedule." Which issue does the nurse conclude is the issue of most concern?
Potential for injury
Which concern is the priority when health care instructions are discussed with a carpenter having trouble holding tools because of a carpal tunnel syndrome who continues to work to meet financial obligations?
Potential for injury
Which nursing intervention would the nurse implement to promote sleep for a client in a health care setting? SATA
Reduce Lighting; Provide activities during the day
Which explanation would the nurse give a client with a fracture of the head of the femur for why Buck extension is being used?
Reduces muscle spasms
Which rationale would a nurse understand as the reason why acetylsalicylic acid is prescribed for a client with rheumatoid arthritis?
Reduction of joint inflammation
Three days after a cast is applied to a client's fractured tibia, the client reports that there is a burning pain over the ankle. The cast over the ankle feels warm to the touch, and the pain is not relieved when the client changes position. Which nursing action is the priority?
Report the client's concerns to the primary health care provider.
Which functional capability would be expected in a client with a spinal cord injury at C6?
Requires some assistance devices for upper extremity us but may be able to help feed and dress himself
Which disorder of the musculoskeletal system is illustrated in the image?
Rheumatoid arthritis (RA) The image depicts rheumatoid arthritis, which is marked by symmetric deformity of the knuckles.
While assessing a client with suspected increased intracranial pressure, the nurse documents anisocoria in the medical reports. Which sign supports the nurse's documentation?
Unequal pupils
Which criterion would a nurse use to determine that appropriate alignments is achieved by the immobilizer device after surgical repair of a client's rotator cuff?
Upper arm lies close to the chest
Which criterion would the nurse use to determine that appropriate alignment is achieved by the shoulder immobilizer device?
Upper arm lies close to the chest.
In which position would the nurse place a client with osteoarthritis who recently had a left total hip replacement?
Use pillows to keep the client's legs abducted.
Which pain assessment method would the nurse use for an adult client with Down syndrome and limitations in mental functioning?
Using the Wong-Baker Faces Pain Rating Scale
Which intervention would be included in the plan of care for an elderly client who has a right hip fracture?
Venous thromboembolism (VTE) prevention
Which drug would likely cause a client's eyelids to itch and eyes to burn?
Vidarabine Vidarabine is an antiviral agent that causes sensitive reactions such as itching eyelids and burning eyes.
Which clinical indicator does the nurse expect to identify when assessing a client with a brain tumor in the occipital lobe?
Visual hallucinations