A nurse is teaching a client with a cerebellar function impairment which statement would the nurse include in this client's discharge teaching?
Ask a friend to drive you to your follow up appointments
The nurse is performing an assessment of cranial nerve III which testing is appropriate
Pupil constriction
During a lumbar puncture which position should the patient be in
Pt should be on the left side knees to chest( fetal position)
An 84 year old client who is usually alert and oriented experiences an acute cognitive decline which of the following factors would the nurse anticipate as contributing to this neurologic change(SATA)
Infection
Drug toxicity
Hypoxia
The nurse is teaching the daughter of a client who has middle stage alzheimer disease the daughter asks will the sertraline my mother is taking improver her dementia how would the nurse respond about the purpose of the drug
It will not improve her dementia but can help control emotional responses
A client with early stage alzheimer disease is admitted to the hospital with chest pain which nursing action is most appropriate to manage this clients dementia
Ensure a structured and consistent environment
The nurse observes a client with late stage alzheimer disease eat breakfast afterward the client states I am hungry and want breakfast what is the nurse's best response
I see you are still hungry I will get you some toast
The nurse is teaching a family caregiver about how best to communicate with the client who has been diagnosed alzheimer disease which statement by the caregiver indicates a need for further teaching
I will avoid communicating with the client to prevent agitation
The nurse teaches assistive personnel (AP) about how to care for a client with early stage alzheimer disease which statement would the nurse include
Reorient the client to the day time and environment with each contact
After teaching the wife of a client who has parkinson disease the nurse assesses the wifes understanding which statement by the clients wife indicates that she correctly understands changes with this disease
He may have trouble chewing so I will offer bite sized portions
The nurse plans care for a client with parkinson disease which intervention would the nurse include in this client's plan of care
Keep the head of the bed at 30 degrees or greater
A nurse teaches assistive personnel(AP) about how to care for a client with parkinson disease which statement would the nurse include as part of this teaching
Allow the client to be as independent as possible with activities
A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis which question would the nurse ask
Do you live in a crowded residence
The nurse plans care for a client with epilepsy who is admitted to the hospital which interventions would the nurse include in this client's plan of care (SATA)
Have suction equipment with an airway at the bedside
Have oxygen administration set at the bedside
Ensure that the client has IV access
The nurse assesses a client who has parkinson disease which signs and symptoms would the nurse recognize as a key feature of this disease(SATA)
Flexed trunk
Slow movements
Uncontrolled drooling
The nurse initiates care for a client with a cervical spine cord injury who arrives via emergency medical services what action would the nurse take first
Evaluate respiratory status
A client who had a complete spinal cord injury at level L5-S1 is admitted with a sacral pressure injury what other assessment finding will the nurse anticipate for this client
Flaccid bowel
The nurse is performing a focused assessment of left posterior temporal lobe functions will assess the patient for
Ability to understand written and oral language
Which problem can the nurse expect for a patient who has a positive romberg test result
Falls
A nurse assesses a client who is recovering from anterior cervical discectomy and fusion which complications should alert the nurse to urgently communicate with the healthcare provider
Auscultated stridor
A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program the client states I don't understand the need for rehabilitation the paralysis will not go away and it will not get better how would the nurse respond
"The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability."
After teaching a client with a high thoracic spinal cord injury the nurse assesses the client's understanding which statement by the client indicates a correct understanding of how to prevent respiratory problems at home
I’ll use my incentive spirometer every 2 hours while i'm awake
A client is scheduled for a percutaneous endoscopic lumbar discectomy which statement by the client indicates a need for further teaching
I'll be in the hospital for 2 to 3 days
A nurse assess clients at a community center which client is at greatest risk for low back pain
A 45-year-old male with osteoarthritis
A nurse assesses a client who is recovering from an open traditional lumbar laminectomy with fusion which complications would the nurse report to the primary healthcare (SATA)
Incisional bulging
Clear drainage on the dressing
Sudden and severe headache
A nurse assess a client with paraplegia from a spinal cord injury and notes reddened areas over the clients hips and sacrum what actions would the nurse take (SATA)
Reposition the client off the reddened areas
Apply a pressure reducing mattress
A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago which assessment findings would the nurse correlate with neurogenic shock (SATA)
Heart rate of 34 beats/min
Urine output less than 30 mL/hr
Decreased level of consciousness
A nurse assesses a client who is recovering from an open traditional anterior cervical fusion which assessment findings would alert the nurse to a complication from this procedure (SATA)
Difficulty swallowing
Hoarse voice
A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide(Cytoxan) and methylprednisolone(Medrol)which statement should the nurse include in this clients discharge teaching
"Avoid crowds and people with colds."
A nurse cares for a client who has been diagnosed with huntington gene but has no symptoms the client ask for options related to family planning what is the nurses best respond
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.
An unconscious male patient has just arrived in the emergency department with a head injury caused by a motorcycle crash which planned intervention by the healthcare provider should the nurse question
Prepare the patient for lumbar puncture
During the neurological assessment the patient is unable to respond verbally to the nurse but cooperates with the nurse's direction to move his hands and feet. What should the suspect as a likely cause of these findings?
damage to the frontal lobe.
The nurse recognizes which pathophysiologic feature as a hallmark of guillain barre syndrome
The immune system destroys the myelin sheath.
A patient who has numbness and weakness of both feet is hospitalized with Guillain barre syndrome the nurse will anticipate that collaborative interventions at this time will include
IV infusion of immunoglobulin (Sandoglobulin).
The nurse advises a patient with myasthenia gravis (MG) to
Perform physically demanding activities early in the day
A patient who has amyotrophic lateral sclerosis(ALS) is hospitalized with pneumonia which nursing action will be included in the plan of care
Assist with active range of motion
A 40 year old patient is diagnosed with early huntington's disease(HD) when teaching the patient the spouse and adult children about this disorder the nurse will provide information about the
Option of genetic testing for the patients children to determine their own HD risk
When a 74 year old patient seen in the health clinic the new development of a stooped posture shuffling gait and pill rolling type tremor the nurse will anticipate teaching the patient about
Antiparkinsonism drugs
A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit which equipment should the nurse have available in the patients assigned room(SATA)
Side rail pads
Suction tubing
Oxygen mask
A patient with parkinson's disease is admitted to the hospital for treatment of pneumonia which nursing interventions will be included in the plan of care(SATA)
Provide an elevated toilet seat
Cuts patients food into small pieces
Place an armchair at the patient's bedside
A patient with bell's palsy refuses to eat while others are present because of embarrassment about drooling the best response by the nurse is to
Respect the patient's feelings and arrange for privacy at mealtimes
A patient hospitalized with a new diagnosis of Guillain Barre syndrome has numbness and weakness of both feet the nurse will anticipate teaching the patient about
Infusion of immunoglobulin
A patient is hospitalized with a new onset of Guillain barre syndrome the most essential assessment for the nurse to complete is
Observing respiratory rate and effort
You suspect bell's palsy in which patient
Sudden onset one sided facial weakness with ear pain and vesicles
A nurse plans care for a 77 year old client who is experiencing age related peripheral sensory perception changes which intervention would the nurse include in the client's plan of care
.
Ensure that the path to the bathroom is free from clutter.
When admitting a patient with acute confusion to the hospital, the nurse will interview the patient about health problems and health history primarily to
assess the patient's baseline cognitive abilities
When teaching patients who are at risk for Bell's palsy because of previous herpes simplex infection, which information should the nurse include?
"You should call the doctor if pain or herpes lesions occur near the ear."
What action should the nurse incorporate when administering a mental status examination to a patient with delirium
Choose a place without distracting stimuli
A patient is diagnosed with moderate dementia after multiple strokes. What would the nurse expect to find during assessment of the patient?
Loss of recent long and term memory
While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take?
Time and observe and record the details of the seizure and postictal state
A nurse teaches a client who is recovering from an open traditional cervical spine fusion which statement would the nurse include in this clients post operative instructions
Wear your neck brace whenever you are out of bed
A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action should the nurse include in the plan of care?
Instruct the patient how to self catheterize
the nurse is caring for a patient who is being evaluated for a possible metastic spinal cord which of these data obtained when assessing the patient requires most immediate action by the nurse
the patient has new onset weakness in both legs
a patient with a history of a T2 spinal cord tells the nurse i feel awful today my head is throbbing and i feel sick to my stomach which action should the nurse take first
check the blood pressure