The nurse is working on a surgical floor. The nurse must log roll a male client following a:
The client who has had spinal surgery, such as laminectomy, must be logrolled to keep the spinal column straight when turning.
The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to:
Fatigue is a common symptom in clients with multiple sclerosis. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. Other measures to reduce fatigue in the client with multiple sclerosis include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity.
A female client with amyotrophic lateral sclerosis (ALS) tells the nurse, “Sometimes I feel so frustrateD. I can’t do anything without help!” This comment best supports which nursing diagnosis?
This comment best supports a nursing diagnosis of Powerlessness because ALS may lead to locked-in syndrome, characterized by an active and functioning mind locked in a body that can’t perform even simple daily tasks.
A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for CVA?
Obesity is a risk factor for CVA. Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, oral contraceptive use, emotional stress, family history of CVA, and advancing age.
A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority for this client’s plan of care?
Because the client is disoriented and restless, the most important nursing diagnosis is risk for injury.
A male client is having tonic-clonic seizures. What should the nurse do first?
Protecting the client from injury is the immediate priority during a seizure.
A female client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?
The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.
For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to:
The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP.
During a routine physical examination to assess a male client’s deep tendon reflexes, the nurse should make sure to:
To prevent the attached muscle from contracting, the nurse should support the joint where the tendon is being tested.
A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test?
Because CT commonly involves the use of a contrast agent, the nurse should determine whether the client is allergic to iodine, contrast dyes, or shellfish.
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