ATI: #3 Targeted Medical-Surgical 2013: Neurosensory and Musculoskeletal Flashcards
SELECT ALL THAT APPLY: A nurse is assessing a client who has a new dx of osteoarthritis. Which of the following findings should the nurse expect?
A. Crepitus with joint movement
B. Decreased range of motion of the affected joint
C. Involvement of smaller joints of the body
D. Spongy tissue over the joints
E. Joint pain that resolves with rest
A. Crepitus with joint movement
B. Decreased range of motion of the affected joint
E. Joint pain that resolves with rest
A nurse is planning care for a client following a lumbar puncture. Which of the following actions should the nurse plan to include?
A. Apply pressure to the site for 12hr
B. Restrict the client’s fluid intake for 24hr
C. Ensure the client lies flat for 4-8hr
D. Administer pain eds every 3-4hr
C. Ensure the client lies flat for 4-8hr
A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which intervention is a priority?
A. Provide for frequent rest periods throughout the day
B. Medicate for pain on a regular schedule
C. Monitor pulse oximetry findings
D. Administer baclofen for spasicity
C. Monitor pulse oximetry findings
A nurse is assessing a client who had a right hemispheric stroke. Which deficit is expected? A. Aphasia B. Right-sided neglect C. Impulsive behavior D. Inability to read
C. Impulsive behavior
Client who is 72hr postop AKA reports phantom limb pain. Which action should the nurse take?
A. Remind the client that the limb has been removed
B. Change the dressing on the client’s residual limb
C. Administer an oral dose of gabapentin to the client
D. Elevated the client’s residual limb above heart level
C. Administer an oral dose of gabapentin (neurontin) to the client
A nurse is teaching a client with Parkinson’s disease about a new prescription for carbidopa-levodopa (Sinemet). Which indicates an understanding?
A. I should epect a slight increase in my BP while taking these meds
B. I should take my meds with a high-protein food
C. I should expect my urine to be darker in color
D. I wll expect it to take up to a week for this medication to work
C. I should expect my urine to be darker in color
PICTURE QUESTION: how to sit post arthroplasty?
Try not to sit in the same position for more than 30 to 40 minutes at a time
Keep your feet about 6 inches apart. Do not bring them all the way together.
Keep your feet and knees pointed straight ahead, not turned in or out.
Sit in a firm chair with a straight back and armrests. Avoid soft chairs, rocking chairs, stools, or sofas.
Avoid chairs that are too low. Your hips should be higher than your knees when you are sitting. Sit on a pillow if you have to.
When getting up from a chair, slide toward the edge of the chair, and use the arms of the chair or your walker or crutches for support.
Do not cross your legs.
Client in ED post sudden LOC fall at home. Provider determines that the client has had an embolic stroke. Which medication should the nurse give?
A. Recombinant tissue plasminogen activator
B. Recombinant factor VIII
C. Nitroglycerin
D. Lidocaine
A. Recombinant tissue plasminogen activator
Client has viral meningitis. What should the nurse do?
A. Assess the client’s neurological status every 8hr
B. Maintain the client on droplet precautions
C. Monitor capillary refill at least every 4hr
D. Place the client in a well-lit environment
C. Monitor capillary refill at least every 4hr
A nurse is teaching a client with epilepsy who is to start phenytoin. Which of the following instructions should the nurse include in the client’s medication teaching plan?
A. Rinse with antiseptic mouthwash in place of using dental floss
B. Use an OTC antihistamine if a rash develops
C. Slowly taper the medication after 6 consecutive months w/o seizure activity
D. Take medication at a consistent time each day to maintain therapeutic blood levels
D. Take medication at a consistent time each day to maintain therapeutic blood levels
A nurse is caring for a client who has MS. What is expected? A. Hypoactive deep-tendon reflexes B. Ascending paralysis C. Intention tremors D. Increased lacrimation
C. Intention tremors
A nurse is caring for a client who has a full arm cast and reports pain of 8 that is unrelieved by pain medication. Which of the following actions should the nurse plan to take first?
A. Administer additional pain medications
B. Check the circulation of the affected extremity
C. Document findings
D. Reposition the affected extremity
B. Check the circulation of the affected extremity
Client with possible head injury following car crash. The nurse recognizes which of the following as in indication of increasing intracranial pressure? A. Restlessness B. Dizziness C. Hypotension D. Fever
A. Restlessness
Client is in balanced suspension skeletal traction and reports intermittent muscle spasms. Which action should the nurse take first? A. Reposition the client B. Provide distraction C. Administer muscle relaxant D. Check position of weights and ropes
D. Check position of weights and ropes
Post-stroke client with right-sided homonymous hemianopsia. The nurse should ?
A. Check the client’s cheek for food
B. Encourage the client to sit upright with his head tilted slightly forward during meals
C. Provide the client with eating utensils that have large handles
D. Remind the client to look consciously at both sides of his meal tray
D. Remind the client to look consciously at both sides of his meal tray
