RN Med Surg Neurosensory & Musculoskeletal
Exam Questions And Answers (Verified)
A nurse is assessing a client who is quadriplegic following a cervical fracture at
vertebral level C5. The client reports a throbbing headache and nausea. The
nurse notes flushing and a blood pressure of 220/110 mm Hg. Which of the
following actions should the nurse take first?
Elevate the head of the client's bed
Explanation: This client is experiencing autonomic dysreflexia and is at risk for cerebral
vessel rupture or increased intracranial pressure. Move the client from supine to an
upright position.
A nurse is caring for a client who is in balanced suspension skeletal traction and
reports intermittent muscle spasms. Which of the following actions should the
nurse take first?
Check the position of the weights and ropes
Explanation: The nurse should check the weights and ropes to see what is the cause of
the muscles spasms.
A nurse in an emergency department is caring for a client who suddenly lost
consciousness and fell while at home. The provider determines that the client had
an embolic stroke. Which of the following medications should the nurse expect to
administer?
Tissue plasminogen activator
Explanation: This is a thrombolytic agent that dissolves the clot that caused the stroke.
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
client's pain?
Client's report of pain on a pain scale
Explanation: Remember the pain is whatever the client says it is. To get an ACCURATE
pain rating you use the pain scale first and back it up with any identifiers like
grimacing/moaning, etc.
A nurse is caring for a client who is recovering from a stroke and has right-sided
homonymous hemianopsia. To help the client adapt to the hemianopsia, the
nurse should take which of the following actions?
Remind the client to look consciously at both sides of their meal tray
Explanation: Homonymous hemianopsia is a condition due to injury of a part of the brain
that disrupts the visual field. It allows the person to only see either to their left or right
side. So reminding them to look at their whole tray is accurate for this scenario because
they might eat the food they can see only.
A nurse is caring for a client who has multiple sclerosis. Which of the following
findings should the nurse expect?
Exam Questions And Answers (Verified)
A nurse is assessing a client who is quadriplegic following a cervical fracture at
vertebral level C5. The client reports a throbbing headache and nausea. The
nurse notes flushing and a blood pressure of 220/110 mm Hg. Which of the
following actions should the nurse take first?
Elevate the head of the client's bed
Explanation: This client is experiencing autonomic dysreflexia and is at risk for cerebral
vessel rupture or increased intracranial pressure. Move the client from supine to an
upright position.
A nurse is caring for a client who is in balanced suspension skeletal traction and
reports intermittent muscle spasms. Which of the following actions should the
nurse take first?
Check the position of the weights and ropes
Explanation: The nurse should check the weights and ropes to see what is the cause of
the muscles spasms.
A nurse in an emergency department is caring for a client who suddenly lost
consciousness and fell while at home. The provider determines that the client had
an embolic stroke. Which of the following medications should the nurse expect to
administer?
Tissue plasminogen activator
Explanation: This is a thrombolytic agent that dissolves the clot that caused the stroke.
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
client's pain?
Client's report of pain on a pain scale
Explanation: Remember the pain is whatever the client says it is. To get an ACCURATE
pain rating you use the pain scale first and back it up with any identifiers like
grimacing/moaning, etc.
A nurse is caring for a client who is recovering from a stroke and has right-sided
homonymous hemianopsia. To help the client adapt to the hemianopsia, the
nurse should take which of the following actions?
Remind the client to look consciously at both sides of their meal tray
Explanation: Homonymous hemianopsia is a condition due to injury of a part of the brain
that disrupts the visual field. It allows the person to only see either to their left or right
side. So reminding them to look at their whole tray is accurate for this scenario because
they might eat the food they can see only.
A nurse is caring for a client who has multiple sclerosis. Which of the following
findings should the nurse expect?
