MSN 377 EXAM 4 VERSION 2023/2024 ALL EXAM QUESTIONS 100% VERIFIED GUARANTEED PASS ALREADY GRADED A LATEST UPDATE

MSN 377 EXAM 4 VERSION 2023/2024 ALL EXAM QUESTIONS 100% VERIFIED GUARANTEED PASS ALREADY GRADED A LATEST UPDATE The nurse advises a patient with myasthenia gravis to A. Perform physically demanding activities early in the day B. Anticipate the need for weekly plasmapheresis treatments C. Do frequent weight -bearing exercise to prevent muscle atrophy D. Protect the extremities from injury due to poor sensory perception A. Perform physically demanding activities early in the day To prevent autonomic hyperreflexia, which nursing action will the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level? A. Support selection of a high -protein d iet B. Discuss options for sexuality and fertility C. Assist in planning a prescribed bowel program D. Use quad coughing to strengthen cough efforts C. Assist in planning a prescribed bowel program Which assessment data for a patient who has Guillain -Barre syndrome will require the nurses most immediate action? A. The patients sacral area skin is reddened B. The patient is continuously drooling saliva C. The patient complains of severe pain in the fe et D. The patients blood pressure is 150/82 B. The patient is continuously drooling saliva The nurse has administered a prescribed IV osmotic diuretic to an unconscious patient. Which parameter should the nurse monitor to determine the medications effectiv eness? A. Blood pressure B. Intracranial pressure C. Oxygen saturation D. Hemoglobin and hematocrit B. Intracranial pressure A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention wil l be included in the plan of care? A. Encourage coughing and deep breathing B. Position the patient with knees and hips flexed C. Keep the head of the bed elevated to 30 degrees D. Cluster nursing interventions to provide rest periods C. Keep the head of t he bed elevated to 30 degrees 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? A. Glasgow coma scale score of 15 B. Intracranial pressure reading of 15mmhg C. Ecchymosis at base of skull D. Clear drainage from nose D. Clear drainage from nose clear drainage indicates that CSF is leaking from the skill 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? A. Tissue plasminogen activator B. Recombinant factor VIII C. Nitroglycerin D. Lidocaine A. Tissue plasminogen activatior a thrombolytic that should dissolve the clot that caused the stroke A nurse is as sessing a client who had a right hemispheric stoke. Which of the following neurologic deficits should the nurse expect? A. Apha sia B. Right sided neglect C. Impulsive behavior D. Inability to read C. Impulsive behavior the nurse should expect impulsive be havior, poor judgment, and lack of awareness of neurologic deficits 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 facial drooping a nd a blood pressure of 220/110. Which of the following actions should the nurse take first? A. Administer hydralazine via IV bolus B. Loosen the clients clothing C. Empty the client's bladder D. Elevate the head of the client's bed D. Elevate the head of t he client's bed indicate autonomic dysreflexia and they are at risk for possible rupture of a cerebral vessel or increased intracranial pressure. The first action the nurse should take is to move the client from supine to an upright position which will re sult in rapid postural hypotension. A nurse is caring for a patient who has a history of status epilepticus and requires seizure precautions. Which of the following actions should the nurse take? A. Assess hourly for a spike in blood pressure B. Keep the c lient on bed rest C. Keep a padded tongue blade at the bedside D. Establish IV access D. Establish IV access The nurse should plan to establish IV access with a large -bore catheter and administer 0.9% sodium chloride if seizures are imminent. If the clien t is stable, the nurse should initiate a saline lock. A nurse is assessing a client who has a head injury following a motor vehicle accident. The nurse should identify that which of the following findings indicates increasing ICP? A. Restlessness B. Dizzin ess C. Hypotension D. Fever A. Restlessness Behavioral changes, such as restlessness and irritability, are early manifestations of increased intracranial pressure. A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? A. Hypoactive deep tendon reflexes B. Ascending paralysis C. Intention tremors D. Increased lacrimation C. Intention tremors Clients who have multiple sclerosis are at risk for motor dysfunction, with intention tremors, poor coord ination, and loss of balance. 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?