Nurse Amber is caring for a client who underwent a lumbar laminectomy two (2) days ago. Which of the following findings should the nurse consider abnormal? A. More back pain than the first postoperative day. B. Paresthesia in the dermatomes near the wounds. C. Urine retention or incontinence. D. Temperature of… Read More »
A client comes into the ER after hitting his head in an MVA. He’s alert and oriented. Which of the following nursing interventions should be done first? A. Assess full ROM to determine extent of injuries. B. Call for an immediate chest x-ray. C. Immobilize the client’s head and neck. D. Open… Read More »
Which client would the nurse identify as being most at risk for experiencing a CVA? A. A 39-year-old pregnant female. B. A 67-year-old Caucasian male. C. An 84-year-old Japanese female. D. A 55-year-old African American male. Correct Answer: D. A 55-year-old African American male. African Americans have… Read More »
After an eye examination, a male client is diagnosed with open-angle glaucoma. The physician prescribes Pilocarpine ophthalmic solution (Pilocar), 0.25% gtt i, OU q.i.D. Based on this prescription, the nurse should teach the client or a family member to administer the drug by: A. Instilling one drop of pilocarpine 0.25% into both eyes daily.… Read More »
A client with a C6 spinal injury would most likely have which of the following symptoms? A. Aphasia B. Hemiparesis C. Paraplegia D. Tetraplegia Correct Answer: D. Tetraplegia Tetraplegia occurs as a result of cervical spine injuries. Cervical injuries lead to the same deficits as thoracic injuries… Read More »
Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? A. A blood glucose level of 480 mg/dl. B. A right-sided carotid bruit. C. A blood pressure of 220/120 mmHg. D. The presence of bronchogenic carcinoma. Correct Answer:… Read More »
A female client who’s paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis? A. The client leaves the side rails down. B. The client uses a mirror to inspect the skin. C.… Read More »
A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority? A. Bladder distension B. Neurological deficit C. Pulse ox readings D. The client’s feelings about the injury Correct Answer: C. Pulse ox… Read More »