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Med-Surg Chapters 44 & 45
Terms in this set (58)
The nurse is caring for a client experiencing migraine headaches who is receiving a beta blocker to help manage this disorder. When preparing a teaching plan, which instruction does the nurse plan to provide?
a. "Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache."
b. "Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches."
c. "This drug will relieve the pain during the aura phase soon after a headache has started."
d. "This medication will have no effect on your heart rate or blood pressure because you are taking it for migraines."
Beta blockers are prescribed as prophylactic treatment to prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure will also be affected, and the client should monitor these side effects. The other responses do not discuss an appropriate use of the medication.
The nurse is assessing a client with a history of migraines. Which clinical manifestation is an early sign of a migraine with aura?
c. Visual disturbances
d. Numbness of the tongue
Early warning of impending migraine with aura usually consists of visual changes, flashing lights, or diplopia. The other manifestations are not associated with an impending migraine with aura.
The nurse is reviewing a client's prescription for sumatriptan succinate (Imitrex). Which condition in this client's medical history does the nurse report to the health care provider?
a. Bronchial asthma
c. Prinzmetal's angina
d. Chronic kidney disease
Sumatriptan succinate effectively reduces pain and other associated symptoms of migraine by binding to serotonin receptors and triggering cranial vasoconstriction. Vasoconstrictive effects are not confined to the cranium and can cause coronary vasospasm in clients with Prinzmetal's angina. The other conditions would not affect the client's treatment.
The nurse is assessing a client with a cluster headache. Which clinical manifestation does the nurse expect to find?
a. Ipsilateral tearing of the eye
c. Abrupt loss of consciousness
d. Neck and shoulder tenderness
Cluster headache is usually accompanied by ipsilateral tearing, rhinorrhea or nasal congestion, ptosis, eyelid edema, facial sweating, and miosis. The other manifestations are not associated with cluster headaches.
A client with epilepsy develops stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How does the nurse document this seizure activity?
a. Atonic seizure
b. Absence seizure
c. Myoclonic seizure
d. Tonic-clonic seizure
Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. The other seizures do not manifest in this manner.
The nurse is assessing a client with a history of absence seizures. Which clinical manifestation does the nurse assess for?
b. Intermittent rigidity
c. Sudden loss of muscle tone
d. Brief jerking of the extremities
Automatisms are characteristic of absence seizures. These behaviors consist of lip smacking, patting, and picking at clothing. The other manifestations do not correlate with absence seizures.
The nurse is caring for a client with a history of epilepsy who suddenly begins to experience a tonic-clonic seizure and loses consciousness. What is the nurse's priority action?
a. Restrain the client's extremities.
b. Turn the client's head to the side.
c. Take the client's blood pressure.
d. Place an airway into the client's mouth.
The nurse should turn the client's head to the side to prevent aspiration and allow drainage of secretions. The client should not be restrained nor an airway placed in his or her mouth during the seizure because these actions increase seizure activity and can harm the client. Vital signs are measured in the postictal phase of the seizure.
A client is actively experiencing status epilepticus. Which prescribed medication does the nurse prepare to administer?
b. Lorazepam (Ativan)
c. Phenytoin (Dilantin)
d. Morphine sulfate
Initially, intravenous lorazepam is administered to stop motor movements. This is followed by the administration of phenytoin. Atropine and morphine are not administered for seizure activity.
A client with new-onset status epilepticus is prescribed phenytoin (Dilantin). After teaching the client about this treatment regimen, the nurse assesses the client's understanding. Which statement indicates that the client understands the teaching?
a. "I must drink at least 2 liters of water daily."
b. "This will stop me from getting an aura before a seizure."
c. "I will not be able to be employed while taking this medication."
d. "Even when my seizures stop, I will take this drug."
Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does not need to drink more water and can continue to work while taking this medication. The medication will not stop an aura before a seizure.
The nurse is teaching a client who is newly diagnosed with epilepsy. Which statement by the client indicates a need for further teaching concerning the drug regimen?
a. "I will not drink any alcoholic beverages."
b. "I will wear a medical alert bracelet."
c. "I will let my doctor know about all of my prescriptions."
d. "I can skip a couple of pills if they make me ill."
The nurse must emphasize that antiepileptic drugs must be taken even if seizure activity has stopped. Discontinuing the medication can predispose the client to seizure activity and status epilepticus. The client should not drink alcohol while taking seizure medications. The client should wear a medical alert bracelet and should make the doctor aware of all medications to prevent complications of polypharmacy.
The nurse assesses for which clinical manifestations in the client with suspected encephalitis?
a. Fever of 101° F (38.3° C)
b. Nausea and vomiting
c. Hypoactive deep tendon reflexes
d. Pain on flexion of the neck
Nuchal rigidity is associated with meningeal irritation and is frequently present in clients with encephalitis. The other manifestations are not associated with encephalitis.
The nurse is taking the health history of a client suspected of having bacterial meningitis. Which question is most important for the nurse to ask?
a. "Do you live in a crowded residence?"
b. "When was your last tetanus vaccination?"
c. "Have you had any viral infections recently?"
d. "Have you traveled out of the country in the last month?"
Meningococcal meningitis tends to occur in outbreaks. It is most likely to occur in areas of high-density population, such as college dormitories, prisons, and military barracks. The other questions do not identify risk factors for bacterial meningitis.
The nurse is talking to the family of a client who has Parkinson's disease. Which statement indicates that the family has a good understanding of the changes in motor movement associated with this disease?
a. "I can never tell what she's thinking. She hides behind a frozen face."
b. "She drools all the time so I just can't take her out anywhere."
c. "I think this disease makes her nervous. She perspires all the time."
d. "She has trouble chewing so I will offer bite-sized portions."
A masklike face, drooling, and excess perspiration are common in clients with Parkinson's disease. Changes in facial expression or a masklike facies in a Parkinson's disease client can be misinterpreted. Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the client's nutritional needs. The other statements indicate poor understanding of the disease process.
The nurse is caring for a client with Parkinson's disease. Which intervention does the nurse implement to prevent respiratory complications in the client?
a. Keep an oral airway at the bedside.
b. Ensure fluid intake of at least 3 L/day.
c. Teach the client pursed-lip breathing techniques.
d. Maintain the head of the bed at 30 degrees or greater.
Elevation of the back rest will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson's disease.
The daughter of a client with Alzheimer's disease asks, "Will the medication my mother is taking improve her dementia?" How does the nurse respond?
a. "It will help your mother live independently once more."
b. "It is used to halt the advancement of Alzheimer's disease but will not cure it."
c. "It will provide a steady improvement in memory but not in problem solving."
d. "It will not improve dementia but can help control emotional responses."
Drug therapy is not effective for treating dementia or halting the advancement of Alzheimer's disease. However, certain drugs may help suppress emotional disturbances and psychiatric manifestations.
A client with Alzheimer's disease is admitted to the hospital. Which psychosocial assessment is most important for the nurse to complete?
a. Ability to recall past events
b. Ability to perform self-care
c. Reaction to a change of environment
d. Relationship with close family members
As the disease progresses, the client experiences changes in emotional and behavioral affect. The nurse should be alert to the client's reaction to a change in environment, such as being hospitalized, because the client may exhibit an exaggerated response, such as aggression, to the event. The other assessments should be completed but are not as important for a client with Alzheimer's disease.
The nurse is caring for a hospitalized client with Alzheimer's disease who has a history of agitation. Which intervention does the nurse implement to help prevent agitation and aggressive behavior in this client?
a. Provide undisturbed sleep.
b. Orient the client to reality.
c. Leave the television turned on.
d. Administer hypnotic drugs as needed.
Fatigue from disturbed sleep increases confusion and behavioral manifestations, such as aggression and agitation. Reality orientation is inappropriate for clients in a later stage of the disease. Constant noise from the TV most likely would agitate the client. Sedation should be used as a last resort.
A hospitalized client with late-stage Alzheimer's disease says that breakfast has not been served. The nurse witnessed the client eating breakfast earlier. Which statement made to this client is an example of validation therapy?
a. "I see you are still hungry. I will get you some toast."
b. "You are confused about mealtimes this morning."
c. "You ate your breakfast 30 minutes ago."
d. "You look tired. Maybe a nap will help."
Use of validation therapy involves acknowledgment of the client's feelings and concerns. This technique has proved more effective in later stages of the disease, when using reality orientation only increases agitation. Telling the client that he or she already ate breakfast may agitate the client. The other statements do not validate the client's concerns.
A client is prescribed levetiracetam (Keppra). Which laboratory tests does the nurse monitor for potential adverse effects of this medication?
a. Serum electrolyte levels
b. Kidney function tests
c. Complete blood cell count
d. Antinuclear antibodies
Adverse effects of levetiracetam (Keppra) include coordination problems and renal toxicity. The other laboratory tests are not affected by levetiracetam.
The caregiver of a client with advanced Alzheimer's disease states, "She is always wandering off. What can I do to manage this restless behavior?" How does the nurse respond?
a. "Allow for a 45-minute daytime nap."
b. "Take the client for frequent walks throughout the day."
c. "Using a Geri-chair may decrease agitation."
d. "Give a mild sedative during periods of restlessness."
Several strategies may be used to cope with restlessness and wandering. Taking the client for frequent walks may decrease restless behavior. Another strategy is to engage the client in structured activities. The other options would not be as helpful.
A client who has Alzheimer's disease is being discharged home. What safety instructions does the nurse include in the teaching plan for the client's caregiver?
a. "Keep exercise to a minimum."
b. "Place a padded throw rug at the bedside."
c. "Install deadbolt locks on all outside doors."
d. "Keep the lights off in the bedroom at night."
Clients with Alzheimer's disease have a tendency to wander, especially at night. If possible, alarms should be installed on all outside doors to alert family members if the client leaves. At a minimum, all outside doors should have deadbolt locks installed to prevent the client from going outdoors unsupervised. The client should be allowed to exercise within his or her limits. Throw rugs are a slip and fall hazard and should be removed. The client may need or want lights on in the bedroom at night.
The nurse is assessing a client with Huntington's disease. Which motor changes does the nurse monitor for in this client?
a. Shuffling gait
b. Jerky hand movements
c. Continuous chewing motions
d. Tremors of the hands during fine motor tasks
An imbalance between excitatory and inhibitory neurotransmitters leads to uninhibited motor movements, such as brisk, jerky, purposeless movements of the hands, face, tongue, and legs. Shuffling gait, continuous chewing motions, and tremors are associated with Parkinson's disease.
The nurse is planning to bathe a client diagnosed with meningococcal meningitis. In addition to gloves, what personal protective equipment does the nurse use?
a. Particulate respirator
b. Isolation gown
c. Shoe covers
d. Surgical mask
Meningeal meningitis is spread via saliva and droplets. Caregivers should wear a surgical mask when within 6 feet of the client and should continue to use Standard Precautions. A particulate respirator, an isolation gown, and shoe covers are not necessary for Droplet Precautions.
A client diagnosed with the Huntington gene but who has no symptoms asks for options related to family planning. Which is the nurse's best response?
a. "Most clients with the Huntington gene do not pass on Huntington disease to their children."
b. "I understand that they can diagnose this disease in embryos. Therefore you could select a healthy embryo from your fertilized eggs for implantation to avoid passing on Huntington disease."
c. "The need for family planning is limited because one of the hallmarks of Huntington disease is infertility."
d. "Tell me more specifically what information you need about family planning so that I can direct you to the right information or health care provider."
The presence of the Huntington gene means that the trait will be passed on to all offspring of the affected person. Understanding options for contraception and conception (e.g., surrogate mother options) and implications for children may require the expertise of a genetic counselor or a reproductive specialist. The other options are not accurate.
The nurse is caring for a client who has chronic migraine headaches. Which complementary health therapy does the nurse suggest?
a. "Place a hot compress on your forehead at the onset of the headache."
b. "Wear dark sunglasses when you are in brightly lit spaces."
c. "Lie down in a darkened room when you experience a headache."
d. "Do not sleep longer than 6 hours at one time."
At the onset of a migraine attack, the client may be able to alleviate pain by lying down and darkening the room. He or she may want both eyes covered and a cool cloth on the forehead. If the client falls asleep, he or she should remain undisturbed until awakening. The other options are not recognized therapies for migraines.
The nurse is planning care for a client with epilepsy. Which precautions does the nurse implement to ensure the safety of the client while in the hospital? (Select all that apply.)
a. Have suction equipment at the bedside.
b. Place a padded tongue at the bedside.
c. Permit only clear oral fluids.
d. Keep bed rails up at all times.
e. Maintain the client on strict bedrest.
f. Ensure that the client has IV access.
A, D, F
The nurse is teaching a client with chronic headaches about headache triggers. Which statements does the nurse include in the client's teaching plan? (Select all that apply.)
a. "Increase your intake of caffeinated beverages."
b. "Increase your intake of fruits and vegetables."
c. "Avoid all alcoholic beverages."
d. "Avoid drinking red wine."
e. "Incorporate physical exercise into your daily routine."
f. "Incorporate an occasional fast into your plan."
B, D, E
The nurse is assessing the results of diagnostic tests on a client's cerebrospinal fluid (CSF). Which values and observations does the nurse correlate as most indicative of viral meningitis? (Select all that apply.)
c. Normal protein level
d. Increased protein level
e. Normal glucose level
f. Decreased glucose level
A, D, E
The nurse is providing health education at a community center. Which instruction does the nurse include as part of client education for the prevention of low back pain?
a. "Participate in a regular exercise program."
b. "Purchase a soft mattress for sleeping comfort."
c. "Wear high-heeled shoes only for special occasions."
d. "Keep your weight within 20% of your ideal body weight."
Exercise can strengthen back muscles, reducing the incidence of low back pain. The other options will not prevent low back pain.
The nurse is caring for a client who has low back pain (LBP) from a work-related injury. Which measures does the nurse incorporate into the client's plan of care?
a. Apply moist heat continuously to the affected area.
b. Use ice packs or ice massage for 1 to 2 hours over the affected area.
c. Apply heat packs for 20 to 30 minutes at least four times daily.
d. Advise the client to avoid hot baths or showers.
Heat increases blood flow to the affected area and promotes healing of injured nerves. However, continuous application of moist heat can promote skin breakdown.
A client who has a herniated disk is being discharged after a percutaneous endoscopic discectomy. Which postprocedure instructions does the nurse provide before discharge?
a. "You should begin an exercise routine which includes walking every day."
b. "You must sleep in a supine position until the bandage is removed."
c. "You may feel numbness or tingling in the legs for 24 hours."
d. "You will need to wear a lumbar brace for 1 week."
After this minimally invasive surgery, clients typically go home the same day or the day after surgery. Clients should be taught to begin the prescribed exercise program immediately after discharge, which includes walking every day. The client should not be restricted to one sleeping position. Clients generally have less pain with this procedure and do not experience numbness or tingling. The client may have a clear or gauze dressing but will not need to wear a lumbar brace.
The nurse is assessing a client who had a discectomy 6 hours ago. Which client complaint requires priority action by the nurse?
a. "I am feeling tired."
b. "My mouth is so dry."
c. "I can't seem to relax and rest."
d. "I am unable to urinate."
Inability to void may indicate damage to the sacral spinal nerves. The other symptoms require the nurse to provide care but are not the priority or a complication of the procedure.
The nurse is providing discharge teaching to a client after a lumbar laminectomy. For which complication does the nurse instruct the client to return to the hospital?
a. Pain at the incision site
b. Decreased appetite
c. Slight redness and itching at the incision site
d. Clear drainage from the incision site
The finding of clear fluid on the dressing after a laminectomy strongly suggests a cerebrospinal fluid leak, which constitutes an emergency. The client has in increased risk of meningitis with a spinal fluid leak. Pain, redness, and itching at the site are normal. The client should be encouraged to eat a healthy diet but does not need to return to the hospital for a decreased appetite.
The nurse is caring for a client who has undergone a spinal fusion. Which specific postoperative instructions does the nurse give this client?
a. "You may lift items up to 10 pounds."
b. "Wear your brace when you are out of bed."
c. "You must remain on bedrest for 48 hours after surgery."
d. "You will need to take steroids to prevent rejection of the bone graft."
Clients who undergo spinal fusion are fitted with a brace that they need to wear throughout the healing process (usually 3 to 6 months) whenever they are out of bed. The client does not need to remain on bedrest for the first 48 hours, should not lift anything, and will not take steroids for rejection prevention.
A client who suffered a spinal cord injury at level T5 several months ago develops a flushed face and blurred vision. On taking vital signs, the nurse notes the blood pressure to be 184/95 mm Hg. Which is the nurse's first action?
a. Palpate the area over the bladder for distention.
b. Place the client in the Trendelenburg position.
c. Administer oxygen via a nasal cannula.
d. Perform bilateral carotid massage.
The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be appropriate.
Emergency medical services arrive to the emergency department with a client who has a cervical spinal cord injury. Which priority assessment does the emergency department nurse perform at this time?
a. Level of consciousness and orientation
b. Heart rate and rhythm
c. Muscle strength and reflexes
d. Respiratory pattern and airway
The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise and may even require intubation. The other assessments should be performed after airway and breathing are assessed.
The nurse is caring for a client who has a vertebral fracture. Which intervention does the nurse implement to prevent deterioration of the client's neurologic status?
a. Reorient the client to time, place, and person.
b. Administer the Mini-Mental State Examination.
c. Immobilize the affected portion of the spinal column.
d. Reposition the client every 2 hours.
The nurse keeps the client in optimal body alignment at all times, avoiding flexion and extension at the site of vertebral injury, to prevent further cord injury or irritability from bone fragments. A brace, traction, or external fixation may be used for this purpose. The other interventions would not prevent deterioration of the client's neurologic status. Assessments would assist with the recognition of neurologic changes but would not prevent them.
A client who experienced a spinal cord injury 1 hour ago is brought to the emergency department. Which prescribed medication does the nurse prepare to administer to this client?
a. Intrathecal baclofen (Lioresal)
b. Methylprednisolone (Medrol)
c. Atropine sulfate
d. Epinephrine (Adrenalin)
Methylprednisolone (Medrol) should be given within 8 hours of the injury. Clients who receive this therapy usually show improvement in motor and sensory function. The other medications are inappropriate for the client.
The nurse is assessing a client with a spinal cord injury at the T5 level. Which clinical manifestation alerts the nurse to the presence of a complication of this injury?
a. Rhinorrhea and epiphora
b. Fever and cough
c. Agitation and restlessness
d. Hip and knee pain
Clients with injuries at or above the T6 vertebra are especially at risk for respiratory complications caused by impaired intercostal muscles. The development of fever and cough should alert the nurse to the possibility of pneumonia. The other manifestations are not related to complications from this type of injury.
The nurse notes reddened areas over the hips and sacrum of a client with paraplegia from a spinal cord injury. Which action does the nurse implement?
a. Massage the reddened areas with a barrier cream.
b. Perform hip flexion and extension range-of-motion (ROM) exercises.
c. Reposition the client so that the reddened area does not bear weight.
d. Ensure that the client sits in a chair at least once each shift.
Reddened areas should not be rubbed because this action could cause more extensive damage to the already fragile capillary system. ROM exercises are used to prevent contractures. The reddened areas should be assessed for blanching. If the skin does not blanch, the area is vulnerable to breakdown. Appropriate interventions to relieve pressure on these areas through positioning, assistive devices, and skin protection should then be used.
The nurse is caring for a client with a lower motor neuron lesion who wishes to achieve bladder control. Which intervention does the nurse implement to effectively stimulate the initiation of voiding for this client?
a. Stroking the inner aspect of the thigh
b. Intermittent catheterization
c. Digital anal stimulation
d. The Valsalva maneuver
In clients with lower motor neuron problems, such as spinal cord injury, performing a Valsalva maneuver or tightening the abdominal muscles are interventions that can initiate voiding. The other interventions do not initiate voiding.
A client who has a lower motor neuron injury experiences a flaccid bowel elimination pattern. Which action does the nurse implement to assist in relieving this client's constipation?
a. Pouring warm water over the perineum
b. Tapping the abdomen from left to right
c. Administering daily tap water enemas
d. Implementing a consistent daily time for elimination
For the client with a lower motor neuron injury, the resulting flaccid bowel may require a bowel program for the client, which includes stool softeners, increased fluid intake, a high-fiber diet, and a consistent elimination time. The other interventions do not assist this client.
A client with paraplegia is scheduled to participate in a rehabilitation program. The client states, "I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better." How does the nurse respond?
a. "If you do not want to participate in the rehabilitation program, I will cancel the order."
b. "Your doctor has helped many clients with your injury and has ordered a rehabilitation program to help you."
c. "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability."
d. "When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first."
Participation in rehabilitation programs has many purposes, including prevention of disability, maintenance of functional ability, and restoration of function. The other responses do not meet the client's needs.
The nurse is teaching a client who has a spinal cord injury how to prevent respiratory problems at home. Which statement indicates that the client correctly understands the teaching?
a. "I will use my incentive spirometer every 2 hours while I'm awake."
b. "I will not drink thick fluids to prevent choking."
c. "I will take cough medicine to prevent excessive coughing."
d. "I will position myself on my right side so I don't aspirate."
Often, the person with a spinal cord injury will have weak intercostal muscles and is at higher risk for developing atelectasis and stasis pneumonia. Using an incentive spirometer every 2 hours helps the client expand her or his lungs more fully and prevents atelectasis. Clients should drink fluids that they can tolerate; usually thick fluids are easy to tolerate. The client should be encouraged to cough and clear secretions. Clients should be placed in high Fowler's position to prevent aspiration.
The nurse assesses for which clinical manifestation in a client with multiple sclerosis (MS) of the relapsing type?
a. Absence of periods of remission
b. Attacks becoming increasingly frequent
c. Absence of active disease manifestations
d. Gradual neurologic symptoms without remission
The classic picture of relapsing-remitting MS is characterized by increasingly frequent attacks. The other manifestations do not correlate with a relapsing type of MS.
The nurse is assessing a client with an early onset of multiple sclerosis (MS). Which clinical manifestation does the nurse expect to see?
a. Hyperresponsive reflexes
b. Excessive somnolence
d. Heat intolerance
Early signs and symptoms of MS include changes in motor skills, vision, and sensation. The other manifestations are later signs of MS.
A client presents with an acute exacerbation of multiple sclerosis. Which prescribed medication does the nurse prepare to administer?
a. Baclofen (Lioresal)
b. Interferon beta-1b (Betaseron)
c. Dantrolene sodium (Dantrium)
d. Methylprednisolone (Medrol)
Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other medications are not appropriate.
A client with multiple sclerosis is being treated with fingolimod (Gilenya). Which clinical manifestation alerts the nurse to an adverse effect of this medication?
a. Periorbital edema
b. Black tarry stools
d. Vomiting after meals
Fingolimod (Gilenya) is an antineoplastic agent that can cause bradycardia, especially within the first 6 hours after administration. The other manifestations are not adverse effects of fingolimod.
The nurse is preparing a client who has multiple sclerosis (MS) for discharge home from a rehabilitation center. The client has been prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which instruction does the nurse include in the teaching plan for the client?
a. "Take warm baths to promote muscle relaxation."
b. "Avoid crowds and people with colds."
c. "Use physical aids such as walkers as little as possible."
d. "Stop using these medications when your symptoms improve."
The client should be taught to avoid people with any type of upper respiratory illness because these medications are immunosuppressive. Warm baths will exacerbate the MS symptoms, assistive devices may be required for safe ambulation, and medication should not be stopped.
Early manifestations of amyotrophic lateral sclerosis (ALS) and multiple sclerosis (MS) are somewhat similar. Which clinical feature of ALS distinguishes it from MS?
c. Muscle weakness
d. Impairment of respiratory muscles
In ALS, progressive muscle atrophy occurs until a flaccid quadriplegia develops. Eventually, the respiratory muscles are involved, and this leads to respiratory compromise.
Which neurologic test or procedure requires the nurse to determine whether an informed consent has been obtained from the client before the test or procedure?
a. Measurement of sensation using the pinprick method
b. Computed tomography of the cranial vault
c. Lumbar puncture for cerebrospinal fluid (CSF) sampling
d. Venipuncture for autoantibody analysis
A lumbar puncture is an invasive procedure with many potentially serious complications. The other assessments or tests are considered noninvasive.
A client is scheduled for magnetic resonance imaging (MRI). Which action does the nurse implement before the test?
a. Ensure that the person does not eat for 8 hours before the procedure.
b. Discontinue all neuroactive medications 3 hours before the procedure.
c. Make sure that the client has an identification bracelet that cannot be removed.
d. Replace the client's gown with metal snaps with one that has cloth ties.
Metal objects are a hazard because of the magnetic field used in the MRI procedure. The other actions are not necessary for MRI.
The nurse is teaching a client who has an unstable thoracic vertebral fracture and is being treated with immobilization before surgery. Which statement does the nurse include in the client's teaching?
a. "You will need to apply an immobilizing brace snugly around your waist when out of bed."
b. "You will remain strapped to the transport back board until the surgical room is ready."
c. "Keep your spine in alignment by not sitting up, arching your back, or twisting in bed."
d. "An incentive spirometer will prevent you from having atelectasis and pneumonia after surgery."
The client with a thoracic vertebral fracture is at risk for spinal cord injury, especially with flexion, extension, or rotation of the trunk. The client will be moved to a more comfortable bed to wait for surgery and will remain on bedrest. Although teaching about how to use an incentive spirometer is important for surgical clients, the incentive spirometer alone does not prevent atelectasis and pneumonia; it only assists the client to breathe deeply.
The nurse is planning care for a client who has a spinal cord injury. Which interdisciplinary team member does the nurse consult with to assist the client with activities of daily living?
a. Social worker
b. Physical therapist
c. Occupational therapist
d. Case manager
The occupational therapist instructs the client in the correct use of all adaptive equipment. In collaboration with the therapists, the nurse instructs family members or the caregiver about transfer skills, feeding, bathing, dressing, positioning, and skin care. The other team members are consulted to assist the client with unrelated issues.
The nurse is discussing advanced directives with a client who has amyotrophic lateral sclerosis (ALS). The client states, "I do not want to be placed on a mechanical ventilator." How does the nurse respond?
a. "You will need to discuss that with your family and health care provider."
b. "Why are you afraid of being placed on a breathing machine?"
c. "What would you like to be done if you begin to have difficulty breathing?"
d. "You will be on the ventilator only until your muscles get stronger."
ALS is an adult-onset upper and lower motor neuron disease, characterized by progressive weakness, muscle wasting, and spasticity, eventually leading to paralysis. Once muscles of breathing are involved, the client must include in the advance directives what is to be done when breathing is no longer possible without intervention. The other statements do not address the client's needs.
The nurse is assessing a client's coping strategies after suffering a traumatic spinal cord injury. Which information related to this assessment is important for the nurse to obtain? (Select all that apply.)
a. Spiritual or religious beliefs
b. Level of pain
c. Family support
d. Level of independence
e. Annual income
f. Previous coping strategies
A, C, D, F
The nurse is teaching a client with a spinal cord tumor about the treatment plan. Which statements indicate that the client correctly understands the teaching? (Select all that apply.)
a. "Because my symptoms occurred so quickly, I am likely to be cured quickly by surgery."
b. "Radiation therapy can shrink the tumor but radiation can cause more problems, too."
c. "I am glad you are here to turn me. Lying in one position for a long time makes my pain worse, even if turning is uncomfortable."
d. "I have put my affairs in order and purchased a burial plot because this type of cancer is almost always fatal."
e. "My family is making some changes at home for me, including moving my bedroom downstairs."
B, C, E
The nurse is teaching a male client with a spinal cord injury at T4 (thoracic) about the sexual effects of this injury. Which statement by the client indicates correct understanding of the teaching? (Select all that apply.)
a. "I will not be able to have an erection because of my injury."
b. "Ejaculation may not be as predictable as before."
c. "I will explore other ways besides intercourse to please my partner."
d. "I may urinate with ejaculation but this will not cause an infection."
e. "I should be able to have an erection with stimulation."
B, D, E
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Neuro Medical-Surgical Nursing, 7th Edition ch 43-…
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