The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which of the following to test the client’s peripheral response to pain? A. Sternal rub B. Nail bed pressure C. Pressure on the orbital rim D. Squeezing of the sternocleidomastoid muscle … Read More »
The nurse is planning care for the client in spinal shock. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury? A. Monitoring vital signs before and during position changes. B. Using vasopressor medications as prescribed. C. Moving the client quickly… Read More »
After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. He’s unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client? A. Give him a barbiturate. B. Place him on mechanical ventilation. C. Perform a… Read More »
A female client admitted to the hospital with a neurological problem asks the nurse whether magnetic resonance imaging may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the client’s history of: A. Hypertension B. Heart failure C. Prosthetic valve replacement D. Chronic… Read More »
The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by: A. Keeping the client on a stretcher. B. Logrolling the client on a firm mattress. C. Logrolling the client on a soft mattress. D. Placing the client on a… Read More »
When obtaining the health history from a male client with retinal detachment, the nurse expects the client to report: A. Light flashes and floaters in front of the eye. B. A recent driving accident while changing lanes. C. Headaches, nausea, and redness of the eyes. D. Frequent episodes of double vision.… Read More »
A male client is having a lumbar puncture performed. The nurse would plan to place the client in which position? A. Side-lying, with a pillow under the hip. B. Prone, with a pillow under the abdomen. C. Prone, in slight-Trendelenburg’s position. D. Side-lying, with the legs, pulled up and head bent… Read More »
The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists? A. Positive reflexes B. Hyperreflexia C. Inability to elicit a Babinski’s reflex. D. Reflex emptying of the bladder. … Read More »
During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client’s: A. Pulse B. Respirations C. Blood pressure D. Temperature Correct Answer: C. Blood pressure Controlling the blood pressure is critical because an intracerebral hemorrhage is the major adverse… Read More »
A female client complains of periorbital aching, tearing, blurred vision, and photophobia in her right eye. Ophthalmologic examination reveals a small, irregular, nonreactive pupil — a condition resulting from acute iris inflammation (iritis). As part of the client’s therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the right eye… Read More »