The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to:
Rest in an air-conditioned room
Increase the dose of muscle relaxants
Avoid naps during the day
A male client is having a tonic-clonic seizures. What should the nurse do
first?
Elevate the head of the bed.
Restrain the client’s arms and legs
Place a tongue blade in the client’s mouth
Take measures to prevent injury
A female client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?
“You may have difficulty believing
this, but the paralysis caused by this disease is temporary.”
“You’ll have to accept the fact that you’re permanently paralyzed. However, you won’t have any sensory loss.”
“It must be hard to accept the permanency of your paralysis.”
“You’ll first regain use of your legs and then your arms.”
The nurse is working on a surgical floor. The nurse must logroll a male client following a:
A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test?
Immobilize the neck before the client is moved onto a stretcher.
Determine whether the client is allergic to iodine, contrast dyes, or shellfish.
Place a cap over the client’s head.
Administer a sedative as ordered
During a routine
physical examination to assess a male client’s deep tendon reflexes, the nurse should make sure to:
Use the pointed end of the reflex hammer when striking the Achilles tendon.
Support the joint where the tendon is being tested.
Tap the tendon slowly and softly
Hold the reflex hammer tightly.
A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident.
Which nursing diagnosis takes highest priority in this client’s plan of care?
Disturbed sensory perception (visual)
Self-care deficient: Dressing/grooming
Impaired verbal communication
A female client with amyotrophic lateral sclerosis (ALS) tells the nurse, “Sometimes I feel so frustrated. I can’t do anything without help!” This comment best supports which nursing diagnosis?
For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to:
Prevent respiratory alkalosis.
Promote carbon dioxide elimination
Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg
Nurse Maureen witnesses a neighbor’s husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to
opens the airway in this victim by using which method?
Modified head tilt-chin lift
The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which plan to use which of the following to test the client’s peripheral response to pain?
Pressure on the orbital rim
Squeezing of the sternocleidomastoid muscle
A female
client admitted to the hospital with a neurological problem asks the nurse whether magnetic resonance imaging may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the client’s history of:
Prosthetic valve replacement
Chronic obstructive pulmonary disorder
A male client is having a lumbar puncture performed. The nurse would plan to place the client in which position?
Side-lying, with a pillow under the hip
Prone, with a pillow under the abdomen
Prone, in slight-Trendelenburg’s position
Side-lying, with the legs pulled up and head bent down onto chest.
The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid?
Head of bed elevated 30 to 45 degrees
A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid:
Is clear and tests negative for glucose
Is grossly bloody in appearance and has a pH of 6
Clumps together on the dressing and has a pH of 7
Separates into concentric rings and test positive of glucose
A male client with a spinal cord
injury is prone to experiencing automatic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?
Strict adherence to a bowel retraining program
Keeping the linen wrinkle-free under the client
Preventing unnecessary pressure on the lower limbs
Limiting bladder catheterization to once every 12 hours
The nurse is caring for the male client who begins to experience
seizure activity while in bed. Which of the following actions by the nurse would be contraindicated?
Loosening restrictive clothing
Restraining the client’s limbs
Removing the pillow and raising padded side rails
Positioning the client to side, if possible, with the head flexed forward
The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that
this condition:
The client has complete bilateral paralysis of the arms and legs.
The client has weakness on the right side of the body, including the face and tongue
The client has lost the ability to move the right arm but is able to walk independently.
The client has lost the ability to move the right arm but is able to walk independently.
The client with a brain attack (stroke) has residual dysphagia.
When a diet order is initiated, the nurse avoids doing which of the following?
Giving the client thin liquids
Thickening liquids to the consistency of oatmeal
Placing food on the unaffected side of the mouth
Allowing plenty of time for chewing and swallowing
Nurse Kristine is trying to communicate with a client with brain attack (stroke) and aphasia. Which of the following actions by the nurse would be least
helpful to the client?
Speaking to the client at a slower rate
Allowing plenty of time for the client to respond
Completing the sentences that the client cannot finish
Looking directly at the client during attempts at speech
A female client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as:
Getting too little exercise
Omitting doses of medication
Increasing intake of fatty foods
The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by:
Eating large, well-balanced meals
Doing muscle-strengthening exercises
Doing all chores early in the day while less fatigued
Taking medications on time to maintain therapeutic blood levels
A male client with Bell’s palsy asks the nurse what has caused this problem. The nurse’s response is based on an understanding that the cause is:
Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem
Unknown, but possibly includes long-term tissue malnutrition and cellular hypoxia
Primary genetic in origin, triggered by exposure
to meningitis
Primarily genetic in origin, triggered by exposure to neurotoxins
The nurse has given the male client with Bell’s palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client states that he or she will:
Exposure to cold and drafts
Massage the face with a gentle upward motion
Wrinkle
the forehead, blow out the cheeks, and whistle
Female client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. The nurse inquires during the nursing admission interview if the client has history of:
Seizures or trauma to the brain
Meningitis during the last 5 years
Back injury or trauma to the spinal cord
Respiratory or gastrointestinal infection during the previous month.
