TARGETED MEDICAL-SURGICAL: NEUROSENSORY AND MUSCULOSKELETAL

TARGETED MEDICAL-SURGICAL: NEUROSENSORY AND MUSCULOSKELETAL A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider? o Glasgow Coma Scale of 15 o Intracranial pressure reading of 15 mm Hg o Ecchymosis at base of skull o Clear drainage from nose (clear drainage from the nose indicates that cerebrospinal fluid is leaking from the skull fracture) A nurse in an emergency department is caring for a client who suddenly lost consciousness and fell in her home. The provider determines that the client had an embolic stroke. Which of the following medications should the nurse administer? o Tissue plasminogen activator (a thrombolytic agent that should dissolve the blood clot that caused the stroke) o Recombinant factor VIII o Nitroglycerin o Lidocaine A nurse is assessing a client who has rheumatoid arthritis. Which of the following assessment findings should the nurse expect? o Unilateral joint involvement o Ulnar deviation (the inflammation that occurs in the hand joints can make them susceptible to deformity from daily use. Ulnar deviation or lateral deviation of the fingers, can occur from opening jars and other similar motions) o Fractures of the spine o Decreased sedimentation rate A nurse is performing a pain assessment for a client who is postoperative. Which of the following findings should the nurse use to determine the severity of the clients pain? o Clients vital sign changes o Clients report of the type of pain o Clients nonverbal communication o Clients report of pain on a pain scale A nurse is teaching a client and his family about the diagnosis and treatment of Alzheimer’s disease. Which of the following statements should the nurse identify as an indication that the family understands the teaching? o “There is a test for Alzheimer’s disease that can establish a reliable diagnosis” o “The goal of medication therapy is to reverse the degeneration changes that can occur in brain tissue” o “Early manifestations of Alzheimer’s disease include mild tremors and muscular rigidity” o “The medications that treat Alzheimer’s disease can help delay cognitive changes” A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect? o Aphasia o Right-sided neglect o Impulsive behavior (someone with right hemispheric stoke will demonstrate impulsive behavior, poor judgment, lack of awareness of neurologic deficits) o Inability to read A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which of the following interventions is the nurses priority? o Provide for frequent rest periods throughout the day