Chapter 41: Assessment of the Nervous System Test Bank Medical Surgical Nursing 9th Edition Ignatavicius Workman

Test Bank Medical Surgical Nursing 9th Edition Ignatavicius Workman MULTIPLE CHOICE 1. A nurse prepares to teach a client who has experienced damage to the left temporal lobe of the brain. Which action should the nurse take when providing education about newly prescribed medications to this client? a. Help the client identify each medication by its color. b. Provide written materials with large print size. c. Sit on the clients right side and speak into the right ear. d. Allow the client to use a white board to ask questions. ANS: C The temporal lobe contains the auditory center for sound interpretation. The clients hearing will be impaired in the left ear. The nurse should sit on the clients right side and speak into the right ear. The other interventions do not address the clients left temporal lobe damage. DIF: Applying/Application REF: 841 KEY: Patient education| brain trauma/injury/tumor MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Psychosocial Integrity 2. A nurse plans care for a client who has a hypoactive response to a test of deep tendon reflexes. Which intervention should the nurse include in this clients plan of care? a. Check bath water temperature with a thermometer. b. Provide the client with assistance when ambulating. c. Place elastic support hose on the clients legs. d. Assess the clients feet for wounds each shift. ANS: B Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and coordination, predisposing the client to falls. The nurse should plan to provide the client with ambulation assistance to prevent injury. The other interventions do not address the clients problem. DIF: Applying/Application REF: 848 KEY: Patient safety| motor/sensory impairment MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort 3. A nurse teaches an 80-year-old client with diminished touch sensation. Which statement should the nurse include in this clients teaching? a. Place soft rugs in your bathroom to decrease pain in your feet. b. Bathe in warm water to increase your circulation. c. Look at the placement of your feet when walking. d. Walk barefoot to decrease pressure ulcers from your shoes. ANS: C Older clients with decreased sensation are at risk of injury from the inability to sense changes in terrain when walking. To compensate for this loss, the client is instructed to look at the placement of her or his feet when walking. Throw rugs can slip and increase fall risk. Bath water that is too warm places the client at risk for thermal injury. The client should wear sturdy shoes for ambulation. DIF: Applying/Application REF: 846 KEY: Patient safety| motor/sensory impairment MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 4. A nurse assesses a clients recent memory. Which client statement confirms that the clients remote memory is intact? a. A young girl wrapped in a shroud fell asleep on a bed of clouds. b. I was born on April 3, 1967, in Johnstown Community Hospital. c. Apple, chair, and pencil are the words you just stated. d. I ate oatmeal with wheat toast and orange juice for breakfast.