The nurse assesses for which predisposing factor for embolic stroke in the history of the client admitted to the hospital after have a brain attack? Seizures Atrial Fib.!! Cererbal Aneurysm The nurse monitors for which clinical manifestation in the client who has experiences a stroke resulting in damage in Wernicke?s area? Communication with rote speech only Inability to comprehend spoken or written words! Slurred speech The nurse correlates which data from the clients Hx as a risk for brain attacks? Seizure disorder Sleep apnea Cocaine abuse! A slent who first exp. Sysmptoms related to a confirmed thrombotic stroke 2 hrs aho is brought to the ICU. Which drug will the nurse prepare to administer? Heparin sodium! Coumadin Neurontin Which nursing intervention for nutrition will the nurse implement to prevent complications from cranial nerve IX impairment in a client who has experienced a stroke? Order a clear liquid diet for the client. Position the client in the upright position with the head slightly forward and flexed during meals!! Weight the client BID. A client with aphasia presents to the ED with a suspected brain attack. Which assessment data would lead the nurse to suspect that this client has had a thrombotic stroke? A sudden loss of motor coordination Nuchal rigidity Who episodes of speech difficulties in the last month!! A client who has had a stroke with left sided hemiparesis has been referred to a rehab center. The client asks why rehab is necessary at this point. Which is the nurse?s best response? A rehab center will help you function at the highest level possible!! Tour physician has ordered this treatment for you Rehab will reverse the damage done The client who has had a stroke combs her hair only on the right side of her head and washes the right side of her face. What is the nurses interpretation of these actions? The client has paralysis or contractures on the left side. The client has poor left-sided motor control The client is unaware of the existence of her left side!! Which nursing intervention will assist in preventing resp. complications in the client with Parkinson?s disease? Ensuring a fluid intake of at least 3/ml QD Keeping an oral airway at bedside Maintaining the back rest elevation at greater than 30 degrees A nurse is prepairing a teaching plan for a client with migraine headaches whi is receiving a beta-blocker to help manage this disorder. Which instruction would be appropriate to relay to this client? Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches!! This drug will relieve the pain during the aura phase soon after a headache has started. Which technique will the nurse use to assess a client for pain sensation using a sharp or dull insterment? Test for sharp and dull sensation randomly!! Test first with eyes open, then with eyes closed. Test sharp sensation then followed by dull A client who experienced a spinal cord injury 1 hour ago is brought to the ED. Which medication will the nurse prepare to admin to this client? Methlyprednisone!! Atropine Epinephrine Which teaching is most appropriate for the cline with Parkinson?s disease? Seizure precautions Isometric exercises Fall precautions!! The nurse correlates which patho process to the client with a diagnosis with MS? Degeneration of axonal bodies interferes with signal transfusions Poor cellular repair mechanism support the proliferation of dysfunctional neurons Damage to the myelin sheath causes an inflammatory response!! In reviewing orders for a client who experiences migraine headaches and who is to be started on sumatriptan succinate (Imitex), which condition in the medical Hx should be reported to the provider? Chronic Kidney disease Prinzmetals angina!! Asthma The nurse requests the client to preform which action for assessing remote memory? Make up a rhyme Ask who brought the client to the clinic Name his or her date of birth!! The nurse correlates which clinical manifestation with cluster headache? Ipsilateral tearing of the eye!! Abrupt loss of consciousness Neck and shoulder tenderness Which deficit will the nurse expect to find in a client who has experienced an injury to the frontal lobe of the brain? Impaired judgment!! Impaired learning Inability to interpret sound The nurse incorporates what safety instructions into the teaching plan for the caregiver of the AD client who is being cared for at home? Keep exercise to a min. Place a padded throw rug at the bedside Install deadbolt locks on all outside doors.!! The nurse implements which action in the client after her or she undergoes a CT scan of the head with contrast medium? Immobilization of the head for 4 hours Maintain sedation for 8 hours post-procedure Increased fluid intake after the procedure!! A clint presents with nausea, vomiting, fever, and a stiff neck. Which information in this clients HX would lead the nurse to suspect that the client has encephalitis? The client has had difficulty sleeping The client works in a day care facility The client has had a recent viral infection!! Which statement indicated that teaching was effective about an MRI scan? I can return to my usual activities immediately after the test!! I need to increase my fluids because of the dye used for the study My urine will be radioactive for the next 48 hours. Which intervention is the highest priority to prevent care provider stress for the family member of a client with Alzheimers disease? Eat a well-balanced diet Limit time spent with the family member with Alzheimers disease Talk with someone about your feelings!! Which medication will the nurse prepare to administer to the client who is experiencing status epilepticus? Atropine Lorazepam (Ativan)!! Propranolol (Inderal) In preparation for MRI the nurse asks the client which question? Do you have allergies to shell fish!! Have you had recent blood transfusions Do you currently use contraceptives The caregiver of a client with advanced AD asks how to manage the clients restless behaviors. Which is the nurses best response? Allow for a 45 min daytime nap Give mild sedative during episodes of restlessness Take the client for frequent walks throughout the day!! Which technique will the nurse use to assist a client with acute low back pain into the Williams position? Place the client in a high Fowlers position with legs elevated Place the client in a supine position and have the client flex the knees Place the client in a semi-Fowlers position and have the client flex the knees!! A hospitalized client with late stage AD says that breakfast has not been served. The nurse witnessed the client eating breakfast earlier. Which statement made by the client is an example of validation therapy? You look tired, maybe a nap will help. I see you are still hungry. I will get you some toast!! You ate your breakfast 30 min ago. In discussing advanced directives, a client with ALS states that he does not want to be placed on a mechanical vent. Which is the nurses best response? You will need to discuss that with your family and physician You may only need to be on a vent until your muscles get stronger What would you like to be done if you have difficulty breathing!! Which of the following is most at risk for developing postural renal failure? Client with CHF Client with renal calculi !! Client taking NSAID?s What must be assessed to confirm the patency of a dialysis shunt? Select all that apply. Thrill!! No need to assess Blood pressure Bruit!! Which is the nurses highest priority for meeting the needs of a client who presents with a 3-day HX of vomiting and diarrhea, blood pressure 85/50 and HR or 106bpm? Relief of nausea Finding the source of the infection Replacement of fluids!! A client with a serum creatine level of 2.5, a potassium of 6 an arterial PH of 7.32 and a urine output of 250ml QD. Which phase of acute renal failure is the client experiencing? Postnural Intranural Oliguric!! A client is admitted to the hospital with a serum Creatinine level of 2. When taking the clients HX, which question will the nurse ask first? Is your diet low in protein Do you take any nonprescription medications !! Does anyone in your family have kidney disease The RN assigned a client with a newly placed AV fistula in his right arm to an LPN. Which information about the care of this client is most important for the RN to provide to the LPN.? Take blood pressure in the left arm!! Start an IV line below the fistula A client with a decreased glomerular filtration rate asks how to prevent further damage to the kidneys. Which is the best response? Avoid taking NSAIDS !! You will need to follow a high protein diet The diuretics you are taking will prevent further damage. A client with acute renal failure and on dialysis asks how much fluid will be permitted each day. What is the nurses best response? Its based on your body weight You will be permitted to drink an amount equal to the urine you excrete plus 500ml!! This is based on the amount of damage Which assessment finding does the nurse associate with the clients acute renal failure, postrenal type? Feeling of urgency!! Elevated Creatinine Weight gain A clint is brought to the ED immediately after head trauma that has results in a FX of the temporal bone. Which clinical manifestation is considered a neurologic emergency in this client? Change in LOC!! Abnormal head tilt Low of vision The nurse correlates which process with the brain damage that results from ICP secondary to cerebral edema? Mylen degeneration from circulating enzymes released in areas of tissue damage. Cerebral tissue hypoxia and ischemia from compression of blood vessels!! Decreased cerebral perfusion from hypotension and blood loss. what nursing intervention with the nurses to prevent complications of inability in a client who has had a stroke?constructing the client to turn the head from side to side. Positioning the client but the unaffected side down. Applying SCD stockings !which question is appropriate for the nurse to ask the family of an older adult presenting to the emergency department in a coma to help determine whether the commas related to brain attack?did the client ever describe weakness in the lower extremities in the past few days? Is there any history of seizure among the client siblings or parents? does the client have a history of drugs or alcohol use!enersys preparing a client for discharge home who is in cotton after a stroke which instructions regarding bladder training with the nurse including the teaching plan for the clients family?instructed client to hold urine as long as possible to restore bladder town. Decrease a clients intake fluid to 1 liter a day. offer the client the commode urinal every 2 hours!the nurse assess is for which predisposing factor for embolic stroke in the history of the quiet minute to the hospital after having a brain attack?seizure atrial fibulation! Cerebral aneurysmwhich statement made by client with newly diagnosed epilepsy indicates that further teaching concerning the drug regimen is necessary? I will wear a medical alert bracelet. I will let my doctor know about this drug when I receive new prescription for other conditions. I can miss up to 2 pills if I run out of them or they may make me ill!!which technique with the nurse use to elicit the Brudzinski reflex in a client being assessed for meningitis?gently flex the clients head and neck on to the checks in there for flexion of the hips and knees! Instructed client to hold both hands back to back while flexing 90 degrees.the class with AD has become disoriented as to time place in advance and is demonstrating speech deficit send contacts. Nurse determines the client is in which stage of AD?Stage 3Stage 1Stage 2!!which diagnostic tests is recognized by the nurses most relevant in the diagnosis for meningitis?complete blood count. Cerebral atrophy. analysis of the cerebral spinal fluid!!the nurse implements which actions in assessing circulation of the clients extremity following cerebral angiograpgy?check pulse is distal to the injection site! Monitor skin turger . Performance examination. Measures orthostatic blood pressure.in taking the history of a client suspected of having bacterial meningitis, which question is most important for the nurse to ask?when was your last tetanus vaccination. Have you had any viral infections recently. Do you live in a crowded residence!!the nurse our caring for a hospitalist client with stage two AD who has a history is agitation. Which intervention will help decrease agitation an aggressive behavior in the clientleaving the television turned on. Providing undisturbed sleep! Orienting the client to reality.the client has arrived by ambulance at the emergency department after having a cervical spinal cord injury. What assessment is priority for the nurse to perform at this time?Mental status. muscle strength and reflexes. Heart rate and rhythm. Respatory pattern in Airway!in providing discharge teaching to a client after a lumbar laminectomy, the nurse instructed client to return to the hospital for which potential complications?decrease appetite. Pain in the incision site. Clear drainage from incision site!the nurse assess is for which clinical manifestation in the client suspected withmeningitis?hypoactive deep tendon reflexes. Nausea and vomiting. Pain on flexion of the neck!for which motor changes in the client with Huntington's disease well there's monitor?unsteady gait. Rapid hand movements with no purpose! Continues chewing motions when the mouth is empty.Im planning discharge for the client with Parkinson's disease, the nurse collaborate with the physical therapist for which outcome?maintaining physical strength and mobility! Monitoring skins for signs of break down. Modifying eating utensils for meals.early manifestations of ALS and MS are someone somewhere. Which clinical feature of ALS distinguishes it from MS.impairment of respiratory muscles! Muscle weakness. Loss of weight.which clinical manifestation is recognized by the nurse as a early warning sign for the client who expenses migraines with aura?lethargy. Vertigo. Visual disturbances!which nursing diagnosis is a priority for the client was autonomic dysreflexia?impaired adjustment related to depression. impaired Urinary elimination related to neurological bladder. Impaired physical mobility related to paraplegia!which instruction with the nurse included as part of clients a cation for the prevention of low back pain?participate in a regular exercise program! Purchase of mattress for sleeping comfort. Keep your weight within 20 percent of your ideal body weight.the daughter of a client with Stage 2 AD asks if the medication at her mother's taking for AD will improve the clients dementia. What is the nurses best response.you will see slow but steady improvement in memory but not in problem solving. Medications do not approve dementia the help control emotional responses!im preventing discharge teaching related to cardiac medications to the client who has experienced damage to the left temporal lobe of the brain, the nurse includes which information?sit on the clients right side! Use a larger print size for written materials. Point out the color of the medication.which clinical manifestations would serve to alert the nurse to the early onset of MS?heat intolerance. Nystagmus and ataxia! Hypertensive reflexes.which clinical manifestation alerts the nurse to the possibility of sciatic nerve impairment in the client with back pain?the client walks with a limp! The client has shuffling gait. The client has pain that radiates down the arm.the nurse determines the MRI is contraindicated in the client with which finding in the medical history?A pace maker ! to protect the client with low back pain from injury which of the following measures does the nurse incorporate into the plan of care.apply moist heat continuously to the back . Applying heat packs for 20 to 30 minutes at least 4 * a day! Advising the client to avoid hot baths or showerson assessment of the clients reflexes the nurse notes that the toes fan out when testing reflexes. What is the nurses next action?relay this abnormal finding to others members of the health care team!!. Exam in the family history for potential genetic disorder. Document the finding andcontinue the assessment.which intervention is most likely to achieve the expected outcome of preventing disorientation in neurological status in a client with a vertebral fracture?immobilize in the affected portion of the spinal column! re orient the client to timeand place in person as needed. Repositioning the car every 2 hours.the nurse suggests which complementry health therapies for the card with chronic migraine headaches?limit all your salt in your diet. Where dark sunglasses in brightly lit spaces. lie down in a darkened room at the onset of the headache!which psychosocial assessment is most important for the client with AD and mild dementia who is admitted to the hospital for diagnostic testing?ability to recall past events. Reaction to a change of environment! Ability to perform self care.a nurse is caring for a client with the history of epilepsy who suddenly begins to experience a tonic clonic seizure and loses consciousness. Which is a nurse's party action?turning the clients head to the side! Restraining the extremities. Placing an airway into the mouth.the client suspected to have mysasthenia graves disease it's about to undergo the tensilon test. which drug winners have available for complications of this test?atropine! Epenephrin. Diphennhydramine.which risk factor does a nurse recognize that may predispose an individual to back pain?obesity! Poor posture. Inherited factors.the nurse assess is for which condition or substance use in the car with clinical manifestations of depressed nervous cellular activity?alkalosis. Acidosis! Caffeine.which physical assessment finding does the nurse expected to observe in a client with myasthenia graves disease?absent deep tendon reflexes. Difficulty or inability to perform to 6 Cardinal positions of gaze!!the climb with epilepsy develop Stephanie in of the muscles of the arms and legs, followed by an immediate loss of consciousness and your candle chimineas. How to nurse document this seizure activity?generalized tonic clonic seizure! Generalized atonic seizure. Generalized absent seizure.for which clinical manifestation in the client with advanced AD who is taking halodrol for the nurse assess?tremors! Diarrhea. cough.what is the nurse position a client who is 4 hours post operative after a supratentiral craniotomy?on the operative side. On the non operative side. Supine, with the head of the bed elevated at least 30 degrees!the nurse assess is for which complication of a client and made it to the ICU after incurring a basilar school fracture?hemorrhage! Pulmonary embolus. Aspiration.the client is brought to the emergency room after motor vehicle accident that has resulted in a head injury. Which assessment will the nurse perform a mediately?motor function. Short term memory. Respiratory status!the nurse correlates action of which medication with the treatment of cerebral edema to client after craniotomy for brain tumor?Decadron!ZantacPlavixthe nurse is preparing to administer manitoll to a client with a severe head injury. Which precaution with the nurse take in this medication?draw op the medication using a filter needle!the family the client with a severe head injury states that they do not understand why the client is being put into drug induced coma when brain damage may be present. What is the nurses best response?the medication will prevent seizures and reducing need for monitoring intracranial pressure. The medication is used to decrease activity of the brain so that additional damage does not occur!the nurse monitors for what complications in a client with compression of the pituitary gland by the brain tumor?SIADH! Pulmonary edema. Diabetes mellitus.the mother a 16 year old client diagnosed with Ewings sarcoma is concerned that her son seems to be angry at everyone in the family. How often respond?this is a typical behavior for teenager. This is a normal stage in the grieving process! You need to set limits with your son.the nurses assessing a client with a body cast. Which is assessment finding indicates a complication that needs to be reported to the health care provider?voiding after meals! Redness around the edges of the cast. Urinary output 40 milliliters per hour.the client ask a nurse how she acquired Paget's disease. Which is the best response?you may have a genetic predisposition! it could be caused by fracture. It's because of a lack of calcium in your diet.and older adult client admitted 2 days ago with a fracture hip, the nurse notes to the clients confused, and restless. What is the nurses first action.administer oxygen!!. Discontinue pain medication. Apply restraints.the nurses can frequent 3 days after a below the knee amputation . Which is a priority intervention?range of motion exercises! Place in the client in a high Fowler's position. Use of a very soft bed mattress.if you mail client as seen at the clinic with a medical diagnosis of osteomalcia When taking the clients history what information is most significant?exercise habits. Dietary intake of vitamin D! Dietary intake of calcium.the nurse is performing in assessment on a client admitted with a fractured left humerus. When the client moves the extremity, the nurse notes the presence of a grading sound. Which is a nurse's best intervention?immobilize the arm! Performance of motion. Administer steroids.the client who had a wrist cast to play 3 days ago calls from home, reporting that the cast is loose enough to slide off. How is the nearest respond?you need a new cast in now that the spelling is decreased! Keep your arm above the level of your heart.which statement regarding a pathologic fracture is true?it is a painless fracture of the hand digits. It occurs when a bone is broken in pieces the skin. Results from minimal trauma to the bone weaken by disease!the nurses came for a client with an external fixator in place in there leg. Which is nurse's priority intervention?setting for signs of infection! Assessing for acute pain.which clinical manifestations will the nurse expect to observe in a client with grade 3 open fracture?an open fracture with minimal skin damage. Is 6 to 8 cm wound with damage to skin, muscle, and nerve tissue!the client newly diagnosed to fibrosarcoma, is most likely to exhibit which behavior?resolution Bargaining denial ! which of the following has the highest priority when the nurse intervenes in the care of a client with severe Paget's disease?relief of pain! Genetic testing. the client diagnost with primary bone sarcoma of the leg is scheduled for tumor removal. Express is fear the loss of function. What is the nurses best response?it's normal to feel this way! The surgery is better than the amputation The surgery was necessary to save a life the client for whom skeltal traction is planned asked for an explanation regarding the purpose of this type of traction. What is the nurses best response?this type of traction will relining bone! This type of traction will prevent you from having low back pain. the nurses came for client with a fractured femur. Which factor in the clients history will impede healing of the fracture?history of smoking peripheral vascular disease!! Oral contraceptive use
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