Neuromusculoskeletal System

65問 • 1年前

Kyla Angelique Son

通報

問題一覧

A nurse identifies which clinical indicator of parasympathetic dominance in a client under stress?

Increased gastrointestinal secretions

Which clinical indicator does a nurse identify when assessing a client with hemiplegia?

Paralysis of one side of the body

The school nurse is attending to a student athlete who reports muscle pain after a practice session. What should the nurse identify as a cause of this pain when providing instruction to the student?

Lactic acid

A client who had an open reduction and internal fixation of a fractured ankle is being discharged. Which behavior indicates the need for further instruction about the use of crutches?

Leaning axillae on the crutches to support the body’s weight

When completing a neurological assessment, the nurse determines that a client has a positive Romberg test. Which finding supports the nurse’s conclusion?

Inability to stand with feet together when eyes are closed

When caring for a client with a head injury that may have involved the medulla, the nurse bases assessments on the knowledge that the medulla controls a variety of functions. Which ones apply? Select all that apply.

Breathing, Pulse rate, Blood vessel diameter

When performing a neurologic assessment of a client, a nurse identifies that the client has a dilated right pupil. The nurse concludes that this suggests a problem with which cranial nerve?

Third

A nurse is assessing a client whose mouth is drawn over to the left. The nurse should consider damage to which cranial nerve to be the most likely explanation for this clinical finding?

Left facial nerve

After a brain attack a client is unable to differentiate between heat or cold and sharp or dull sensory stimulation. What lobe of the brain should the nurse conclude is likely affected?

Parietal

A client experiences a traumatic brain injury. Which finding identified by the nurse indicates damage to the upper motor neurons?

Babinski response

A nurse is caring for an anxious, fearful client. Which client response indicates sympathetic nervous system control?

Skin pallor

When transporting a client on a stretcher, the nurse makes certain that the client’s arms do not hang down over the edge. To which nerve plexus does the nurse avoid injury by taking this precaution?

Brachial

A client has a craniotomy for a meningioma. For what response should the nurse assess the client in the postanes- thesia care unit?

Blurred vision

A client is to have a computed tomography (CT) scan with contrast to assess a potential brain tumor. The nurse should teach the client what common expected responses to the contrast material? Select all that apply.

Sensation of warmth, Flushing of the face

A nurse is monitoring a client who is having a computed tomography (CT) scan of the brain with contrast. Which response indicates that the client is having an untoward reaction to the contrast medium?

Shortness of breath

A client with glaucoma asks a nurse about future treatment and precautions. What information should the nurse’s expla- nation include?

Continuation of therapy for life

A client is admitted with paresis of the ciliary muscles of the left eye. What function should the nurse expect to be affected?

Focusing the lens on near objects

Which desired effect of therapy should the nurse explain to the client who has primary angle-closure glaucoma?

Controlling intraocular pressure

Which clinical indicator is the nurse most likely to identify when exploring the history of a client with open-angle glaucoma?

Impairment of peripheral vision

A client’s relative asks the nurse what a cataract is. What explanation should the nurse provide?

An opacity of the lens

What should the nurse do for a client who just had cataract surgery?

Advise the client to refrain from vigorous brushing of the teeth and hair.

A nurse is caring for a client who is scheduled for surgery for a detached retina. Which goal of surgery identified by the client indicates that the preoperative teaching was effective?

Create a scar that aids in healing retinal holes

A nurse performs a Rinne test during physical assessment of a client. The client indicates that the sound is louder when the vibrating tuning fork is placed against the mastoid bone than when held closely to the ear. What conclusion should the nurse make about these results?

This is evidence of a conductive hearing loss.

A client is scheduled for a labyrinthectomy to treat Ménière syndrome. What expected outcome of the procedure should be included in preoperative teaching?

Permanent irreversible deafness

A nurse is developing a teaching plan for a client with otosclerosis. What information should the nurse include in the teaching plan?

Hearing aids usually restore some hearing.

What clinical indicator does the nurse expect to identify when assessing a client with a brain tumor in the occipital lobe?

Visual hallucinations

A client is to have a parotidectomy to remove a cancerous lesion. For which postoperative complication that may be permanent should the nurse monitor?

Facial nerve dysfunction

A client who is receiving phenytoin (Dilantin) to control a seizure disorder questions the nurse regarding this medica- tion after discharge. The nurse’s best response is “This medication:

will probably be continued for life.”

A client with a history of seizures is admitted with a partial occlusion of the left common carotid artery. The client has been taking phenytoin (Dilantin) for 10 years. When plan- ning care for this client, what should the nurse do first?

Obtain a history of seizure type and incidence.

When entering a room on a medical unit, the nurse identifies that a client is having a seizure. What should the nurse do in addition to protecting the client from self-injury?

Monitor the seizure activity.

What is the primary responsibility of a nurse during a client’s generalized motor seizure?

Clearing the immediate environment for client safety

A client who has a history of seizures is scheduled for an arteriogram at 10 AM and is to have nothing by mouth before the test. The client is scheduled to receive an anticonvulsant medication at 9 AM. What should the nurse do?

Ask the health care provider if the drug can be given IV.

Several clients are admitted to the emergency department with brain injuries as a result of an automobile collision. The nurse concludes that the client with an injury to which part of the brain will most likely not survive?

Medulla

After sustaining a head trauma, a client reports hearing ringing noises. The nurse considers that an injury to what part of the body is likely to cause this clinical indicator?

Eighth cranial nerve (vestibulocochlear)

A nurse should expect to identify a loss of which ability when assessing an unconscious client?

Controlling elimination

A client regains consciousness and has expressive aphasia. What should the nurse include as part of long-range planning for this client?

Provide positive feedback when the client uses a word correctly.

Soon after admission to the hospital with a head injury, a client’s temperature increases to 102.2° F (39° C). The nurse considers that the client has sustained injury to what structure?

Hypothalamus

What action should the nurse take when caring for a client who has a possible skull fracture as a result of trauma?

Monitor the client for signs of brain injury.

A nurse is assessing a client with a brain tumor. Which clini- cal findings indicate an increase in intracranial pressure? Select all that apply. 1. Fever 2. Stupor 3. Orthopnea 4. Rapid pulse 5. Hypotension

1. Fever, 2. Stupor

What therapeutic effect does the nurse expect to identify when mannitol (Osmitrol) is administered parenterally to a client with cerebral edema?

Decreased intracranial pressure

A client had a craniotomy for excision of a brain tumor. After surgery, the nurse monitors the client for increased intracranial pressure. Which clinical finding supports an increase in intracranial pressure?

Lowered level of consciousness

When caring for a client who has sustained a head injury, it is important that the nurse assess for which clinical indicator?

Slowing of the heart rate

A client develops hydrocephalus 2 weeks after cranial surgery for a ruptured cerebral aneurysm. The nurse concludes that the hydrocephalus probably is related to which physiologic response?

Blocked absorption of fluid from the arachnoid space

What should the nurse assess for in the immediate postoperative period after a client has brain surgery?

Decreased level of consciousness

What nursing action is essential when a client experiences hemianopsia as the result of a left ischemic stroke?

Place objects within the visual field.

During a health fair, the nurse takes an adult’s blood pressure and it is 200/120 mm Hg. The nurse should base the next nursing intervention on the understanding that:

there is an increased risk for having a brain attack.

Which health problem does the nurse identify from an older client’s history that increases the client’s risk factors for a brain attack?

Transient ischemic attacks

Which clinical indicator is the nurse most likely to identify when assessing a client with a ruptured cerebral aneurysm?

Sudden severe headache

A client with a brain attack is comatose on admission. Which clinical indicator is the nurse most likely to identify?

Urinary incontinence

In which position should the nurse initially place a client who has experienced a brain attack?

Lateral

The family members of a client with the diagnosis of brain attack (CVA) express concern that the client often becomes uncontrollably tearful during their visits. What should the nurse include in a response?

Emotional lability is associated with brain trauma.

Which function must be addressed in the plan of care when a client has dysphagia?

Swallowing

A client with a brain attack has dysarthria. What should the nurse include in the plan of care to address this problem?

Effective communication

A client with a brain attack has right hemiplegia. What occurs if the nurse uses the client’s right arm to obtain a blood pressure reading?

Produces inaccurate readings

Bed rest is ordered after a client’s brain attack results in hemiplegia. Which exercises should the nurse incorporate into the client’s plan of care 24 hours after the brain attack?

Passive range-of-motion exercises

Which clinical indicators does the nurse identify that suggest that a client is experiencing urinary retention and overflow after a brain attack? Select all that apply. 1. Edema 2. Oliguria 3. Frequent voidings 4. Suprapubic distention 5. Continual incontinence

Frequent voidings, Suprapubic distention

A client has left hemiplegia because of a brain attack. What can the nurse do to contribute to the client’s rehabilitation?

Position the client to prevent contractures.

A client had a brain attack and bed rest is ordered. What can the nurse use to best prevent footdrop in this client?

Splints

What is the maximum amount of time the nurse should allow an older adult with a brain attack to remain in one position?

1 to 2 hours

A client with a hemiparesis is reluctant to use a cane. The nurse explains to the client that the cane is needed to:

maintain balance to improve stability.

On which principle should a nurse base client teaching when planning to assist a client to reestablish a regular pattern of defecation?

Peristalsis is initiated by the gastrocolic reflex.

A nurse may find that, for optimum nutrition, a client with a brain attack needs assistance with eating. What should the nurse do?

Encourage the client to participate in the feeding process.

A client with a brain attack becomes incontinent of feces. What is the most important nursing action to support the success of a bowel training program?

Adhering to a definite time for attempted evacuations

A nurse is caring for a client who has urinary incontinence as the result of a brain attack. What action should the nurse include in the plan of care to limit the occurrence of urinary incontinence?v

Institute measures to prevent constipation.

The spouse of a client who had a brain attack seems unable to accept the concept that the client must be encouraged to participate in self-care. What is the best response by the nurse?

Ask the spouse for assistance in planning those activities most helpful to the client.

Astignars random QS

Kyla Angelique Son · 19問 · 1年前

Astignars random QS

19問 • 1年前

Kyla Angelique Son

Pharma Cardio

Kyla Angelique Son · 19問 · 1年前

Pharma Cardio

19問 • 1年前

Kyla Angelique Son

Childbearingand Women’s Health

Kyla Angelique Son · 29問 · 1年前

Childbearingand Women’s Health

29問 • 1年前

Kyla Angelique Son

Major DisordersAffecting Women’s Health

Kyla Angelique Son · 36問 · 1年前

Major DisordersAffecting Women’s Health

36問 • 1年前

Kyla Angelique Son

Foundations of Mental Health/Psychiatric Nursing

Kyla Angelique Son · 29問 · 1年前

Foundations of Mental Health/Psychiatric Nursing

29問 • 1年前

Kyla Angelique Son

The Practice of Mental Health/Psychiatric Nursing

Kyla Angelique Son · 67問 · 1年前

The Practice of Mental Health/Psychiatric Nursing

67問 • 1年前

Kyla Angelique Son

Circulatory System

Kyla Angelique Son · 126問 · 1年前

Circulatory System

126問 • 1年前

Kyla Angelique Son

Respiratory System

Kyla Angelique Son · 78問 · 1年前

Respiratory System

78問 • 1年前

Kyla Angelique Son

Gastrointestinal

Kyla Angelique Son · 56問 · 1年前

Gastrointestinal

56問 • 1年前

Kyla Angelique Son

Gastrointestinal 2

Kyla Angelique Son · 55問 · 1年前

Gastrointestinal 2

55問 • 1年前

Kyla Angelique Son

Research

Kyla Angelique Son · 97問 · 1年前

Research

97問 • 1年前

Kyla Angelique Son

Disorders Related to Alterations in Cognition and Perception

Kyla Angelique Son · 47問 · 1年前

Disorders Related to Alterations in Cognition and Perception

47問 • 1年前

Kyla Angelique Son

Anxiety and Alterations in Mood

Kyla Angelique Son · 86問 · 1年前

Anxiety and Alterations in Mood

86問 • 1年前

Kyla Angelique Son

Alterations in Behavior

Kyla Angelique Son · 43問 · 1年前

Alterations in Behavior

43問 • 1年前

Kyla Angelique Son

Communicable dx

Kyla Angelique Son · 27問 · 1年前

Communicable dx

27問 • 1年前

Kyla Angelique Son

NP2

Kyla Angelique Son · 46問 · 1年前

NP2

46問 • 1年前

Kyla Angelique Son

NP4

Kyla Angelique Son · 58問 · 1年前

NP4

58問 • 1年前

Kyla Angelique Son

PALMR

Kyla Angelique Son · 48問 · 1年前

PALMR

48問 • 1年前

Kyla Angelique Son

Sexual andGender Identity Disorders

Kyla Angelique Son · 12問 · 1年前

Sexual andGender Identity Disorders

12問 • 1年前

Kyla Angelique Son

問題一覧

A nurse identifies which clinical indicator of parasympathetic dominance in a client under stress?

Increased gastrointestinal secretions

Which clinical indicator does a nurse identify when assessing a client with hemiplegia?

Paralysis of one side of the body

The school nurse is attending to a student athlete who reports muscle pain after a practice session. What should the nurse identify as a cause of this pain when providing instruction to the student?

Lactic acid

A client who had an open reduction and internal fixation of a fractured ankle is being discharged. Which behavior indicates the need for further instruction about the use of crutches?

Leaning axillae on the crutches to support the body’s weight

When completing a neurological assessment, the nurse determines that a client has a positive Romberg test. Which finding supports the nurse’s conclusion?

Inability to stand with feet together when eyes are closed

Breathing, Pulse rate, Blood vessel diameter

When performing a neurologic assessment of a client, a nurse identifies that the client has a dilated right pupil. The nurse concludes that this suggests a problem with which cranial nerve?

Third

A nurse is assessing a client whose mouth is drawn over to the left. The nurse should consider damage to which cranial nerve to be the most likely explanation for this clinical finding?

Left facial nerve

After a brain attack a client is unable to differentiate between heat or cold and sharp or dull sensory stimulation. What lobe of the brain should the nurse conclude is likely affected?

Parietal

A client experiences a traumatic brain injury. Which finding identified by the nurse indicates damage to the upper motor neurons?

Babinski response

A nurse is caring for an anxious, fearful client. Which client response indicates sympathetic nervous system control?

Skin pallor

Brachial

A client has a craniotomy for a meningioma. For what response should the nurse assess the client in the postanes- thesia care unit?

Blurred vision

Sensation of warmth, Flushing of the face

Shortness of breath

A client with glaucoma asks a nurse about future treatment and precautions. What information should the nurse’s expla- nation include?

Continuation of therapy for life

A client is admitted with paresis of the ciliary muscles of the left eye. What function should the nurse expect to be affected?

Focusing the lens on near objects

Which desired effect of therapy should the nurse explain to the client who has primary angle-closure glaucoma?

Controlling intraocular pressure

Which clinical indicator is the nurse most likely to identify when exploring the history of a client with open-angle glaucoma?

Impairment of peripheral vision

A client’s relative asks the nurse what a cataract is. What explanation should the nurse provide?

An opacity of the lens

What should the nurse do for a client who just had cataract surgery?

Advise the client to refrain from vigorous brushing of the teeth and hair.

A nurse is caring for a client who is scheduled for surgery for a detached retina. Which goal of surgery identified by the client indicates that the preoperative teaching was effective?

Create a scar that aids in healing retinal holes

This is evidence of a conductive hearing loss.

A client is scheduled for a labyrinthectomy to treat Ménière syndrome. What expected outcome of the procedure should be included in preoperative teaching?

Permanent irreversible deafness

A nurse is developing a teaching plan for a client with otosclerosis. What information should the nurse include in the teaching plan?

Hearing aids usually restore some hearing.

What clinical indicator does the nurse expect to identify when assessing a client with a brain tumor in the occipital lobe?

Visual hallucinations

A client is to have a parotidectomy to remove a cancerous lesion. For which postoperative complication that may be permanent should the nurse monitor?

Facial nerve dysfunction

A client who is receiving phenytoin (Dilantin) to control a seizure disorder questions the nurse regarding this medica- tion after discharge. The nurse’s best response is “This medication:

will probably be continued for life.”

Obtain a history of seizure type and incidence.

When entering a room on a medical unit, the nurse identifies that a client is having a seizure. What should the nurse do in addition to protecting the client from self-injury?

Monitor the seizure activity.

What is the primary responsibility of a nurse during a client’s generalized motor seizure?

Clearing the immediate environment for client safety

Ask the health care provider if the drug can be given IV.

Medulla

After sustaining a head trauma, a client reports hearing ringing noises. The nurse considers that an injury to what part of the body is likely to cause this clinical indicator?

Eighth cranial nerve (vestibulocochlear)

A nurse should expect to identify a loss of which ability when assessing an unconscious client?

Controlling elimination

A client regains consciousness and has expressive aphasia. What should the nurse include as part of long-range planning for this client?

Provide positive feedback when the client uses a word correctly.

Soon after admission to the hospital with a head injury, a client’s temperature increases to 102.2° F (39° C). The nurse considers that the client has sustained injury to what structure?

Hypothalamus

What action should the nurse take when caring for a client who has a possible skull fracture as a result of trauma?

Monitor the client for signs of brain injury.

1. Fever, 2. Stupor

What therapeutic effect does the nurse expect to identify when mannitol (Osmitrol) is administered parenterally to a client with cerebral edema?

Decreased intracranial pressure

Lowered level of consciousness

When caring for a client who has sustained a head injury, it is important that the nurse assess for which clinical indicator?

Slowing of the heart rate

A client develops hydrocephalus 2 weeks after cranial surgery for a ruptured cerebral aneurysm. The nurse concludes that the hydrocephalus probably is related to which physiologic response?

Blocked absorption of fluid from the arachnoid space

What should the nurse assess for in the immediate postoperative period after a client has brain surgery?

Decreased level of consciousness

What nursing action is essential when a client experiences hemianopsia as the result of a left ischemic stroke?

Place objects within the visual field.

During a health fair, the nurse takes an adult’s blood pressure and it is 200/120 mm Hg. The nurse should base the next nursing intervention on the understanding that:

there is an increased risk for having a brain attack.

Which health problem does the nurse identify from an older client’s history that increases the client’s risk factors for a brain attack?

Transient ischemic attacks

Which clinical indicator is the nurse most likely to identify when assessing a client with a ruptured cerebral aneurysm?

Sudden severe headache

A client with a brain attack is comatose on admission. Which clinical indicator is the nurse most likely to identify?

Urinary incontinence

In which position should the nurse initially place a client who has experienced a brain attack?

Lateral

Emotional lability is associated with brain trauma.

Which function must be addressed in the plan of care when a client has dysphagia?

Swallowing

A client with a brain attack has dysarthria. What should the nurse include in the plan of care to address this problem?

Effective communication

A client with a brain attack has right hemiplegia. What occurs if the nurse uses the client’s right arm to obtain a blood pressure reading?

Produces inaccurate readings

Bed rest is ordered after a client’s brain attack results in hemiplegia. Which exercises should the nurse incorporate into the client’s plan of care 24 hours after the brain attack?

Passive range-of-motion exercises

Frequent voidings, Suprapubic distention

A client has left hemiplegia because of a brain attack. What can the nurse do to contribute to the client’s rehabilitation?

Position the client to prevent contractures.

A client had a brain attack and bed rest is ordered. What can the nurse use to best prevent footdrop in this client?

Splints

What is the maximum amount of time the nurse should allow an older adult with a brain attack to remain in one position?

1 to 2 hours

A client with a hemiparesis is reluctant to use a cane. The nurse explains to the client that the cane is needed to:

maintain balance to improve stability.

On which principle should a nurse base client teaching when planning to assist a client to reestablish a regular pattern of defecation?

Peristalsis is initiated by the gastrocolic reflex.

A nurse may find that, for optimum nutrition, a client with a brain attack needs assistance with eating. What should the nurse do?

Encourage the client to participate in the feeding process.

A client with a brain attack becomes incontinent of feces. What is the most important nursing action to support the success of a bowel training program?

Adhering to a definite time for attempted evacuations

A nurse is caring for a client who has urinary incontinence as the result of a brain attack. What action should the nurse include in the plan of care to limit the occurrence of urinary incontinence?v

Institute measures to prevent constipation.

The spouse of a client who had a brain attack seems unable to accept the concept that the client must be encouraged to participate in self-care. What is the best response by the nurse?

Ask the spouse for assistance in planning those activities most helpful to the client.