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Terms in this set (18)
A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect?
A. Fluctuations in blood pressure
B. Loss of cognitive function
C. Ineffective cough
D. Drooping eyelids
B. Loss of cognitive function
A nurse is beginning a physical assessment of a client who has a new diagnosis of multiple sclerosis. Which of the following findings should the nurse expect? Select all that apply.
A. Areas of paresthesia
B. Involuntary eye movements
C. Alopecia
D. Increased salivation
E. Ataxia
A, B, E.
Paresthesia is a finding in a client with MS.
Nystagmus is a finding in a client with MS.
Ataxia occurs in the client with MS as muscle weakness develops and there is loss of coordination.
A nurse is teaching a client who has multiple sclerosis and a new prescription for baclofen. Which of the following statements should the nurse include in the teaching?
A. "This medication will help you with your tremors."
B. "This medication will help you with your bladder function."
C. "This medication may cause your skin to bruise easily."
D. "This medication may cause
your skin to appear yellow in color."
D. "This medication may cause your skin to appear yellow in color."
Med to help with spasms. Adverse effect of this medication is jaundice. Can indicate impaired liver function.
A nurse is caring for a client who was recently admitted to the ED following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time?
A. Keep neck stabilized
B. Insert nasogastric tube
C. Monitor pulse and blood pressure frequently
D. Establish IV access and start fluid replacement
A. Keep neck stabilized
The greatest risk to the client is permanent damage to the spinal cord if a cervical injury does exist.
A nurse is caring for a client who has just been admitted following a surgical evacuation of a subdural hematoma. Which of the following is the priority assessment?
A. Glasgow Coma Scale
B. Cranial Nerve Function
C. Oxygen saturation
D. Pupillary response
C. Oxygen saturation
ABC's. Brain tissue can only survive for 3 minutes before permanent damage occurs.
A nurse is caring for a client who has a closed-head injury with ICP readings ranging from 16 to 22 mmHg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? Select all that apply.
A. Suction the ET tube frequently
B. Decrease the noise level in the clients room
C. Elevate the client's head on two pillows
D. Administer a stool softener
E. Keep the client well hydrated
B, D.
Decrease the noise level can decrease ICP
level.
Stool softener decreases the need to bear down during BM's, which can increase ICP.
A nurse in the Critical care unit is completing an admission assessment of a client who has a GSW to the head. Which of the following assessment findings are inidicative of increased ICP? Select all that apply.
A. Headache
B. Dilated Pupils
C. Tachycardia
D. Decorticate posturing
E. Hypotension
A, B, D.
Headache, Dilated pupils, and decorticate/decerebrate posturing are all findings associated with increased ICP.
A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor?
A. Hyperglycemia
B. Hyponatremia
C. Hypervolemia
D. Oliguria
B. Hyponatremia
Mannitol is a powerful osmotic diuretic. Adverse effects include electrolyte imbalances, such as hyponatremia.
A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following findings are expected? Select all that apply.
A. Impulse control difficulty
B. Left hemiplegia
C. Loss of depth perception
D. Aphasia
E. Lack of situational awareness
A, B, C, E.
A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention?
A. Teach the client to scan to the right to see objects on the right side of her body
B. Place the bedside table on the right side of the bed
C. Orient the client to the food on her plate using the clock method
D. Place the wheelchair on the clients left side
B. Place the bedside table on the right side of the bed
The client is unable to visualize to the left midline of her body. If its on the right, she will be able to see it at all times.
A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? Select all that apply.
A. Have suction equipment available
B. Feed the client thickened liquids
C. Place food on the unaffected side of
the client's mouth
D. Assign an assistive perssonnel to feed the client slowly
E. Teach the client to swallow with her neck flexed
A, B, C, E.
Prevents aspiration.
A nurse is caring for a client who has global aphasia (both receptive and expressive). Which if the following should the nurse include in the clients plan of care? Select all that apply.
A. Speak to the client at a slower rate
B.
Assist the client to use flash cards with pictures
C. Speak to the client in a loud voice
D. Complete sentences that the client cannot finish
E. Give instructions one step at a time.
A, B, E.
Slower rate, alternative forms of communication (pictures), and simple step commands.
A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding?
A. Impulse control difficulty
B. Poor judgement
C. Inability to recognize familiar objects
D. Loss of depth perception
C. Inability to recognize familiar objects.
Known as agnosia.
A nurse is planning care for a client who has a spinal cord injury involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurse's highest priority?
A. Prevention of further damage to the spinal cord
B. Prevention of contractors of the lower extremities
C. Prevention of skin breakdown of areas that lack sensation
D. Prevention of postural hypotension when placing the client in a wheelchair
A. Prevention of further damage to the spinal cord
Prevent further damage by administering glucocorticoids, minimizing movement of the client until spine stabilization is accomplished through traction or surgery, and adequate O2 to decrease ischemia of the spinal cord.
A nurse is caring for a client who has a spinal cord injury who reports a severe headache and is sweating profusely. VS: BP 220/110 mm Hg, Apical HR 54/min. Which of the following actions should the nurse take first?
A. Notify the provider
B. Sit the client upright in bed
C. Check the urinary catheter for a blockage
D.
Administer antihypertensive medication
B. Sit the client upright in bed
The greatest risk to the client is CVA, secondary to elevated bp caused by autonomic dysreflexia. Raising the HOB can lower the BP due to postural hypotension.
A nurse is caring for a client who has a C4 spinal cord injury. The nurse should recognize the client is at greatest risk for which of the following complications?
A.
Neurogenic shock
B. Paralytic ileus
C. Stress ulcer
D. Respiratory compromise
D. Respiratory compromise
Maintenance of an airway and provision of ventilatory support as needed is the priority intervention. ABCs.
A nurse is caring for a client who experienced a cerpical spine injury 24 hours ago. Which of the following types of prescribed meds should the nurse clarify with the provider?
A.
Glucocorticoids
B. Plasma expanders
C. H2 antagonists
D. Muscle relaxants
D. Muscle relaxants
The client will not experience muscle spasms until after the spinal shock has resolved, making muscle relaxants unnecessary at this time.
A nurse is caring for a client who experienced a cervical spine injury 3 months ago. Th nurse should plan to implement which of the following types of bladder management methods?
A. Condom catheter
B. Intermittent urinary catheterization
C. Crede's method
D. Indwelling urinary catheter
A. Condom catheter
Noninvasive method, because the bladder will empty on its own due to the client having an UPPER MOTOR NEURON injury, which is manifested by a spastic bladder.
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