NURSING 335 Neurosensory and Musculoskeletal - Questions And Answers (100% Correct)

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? o Glasgow Coma Scale of 15 o Intracranial pressure reading of 15 mm Hg o Ecchymosis at base of skull o Clear drainage from nose (clear drainage from the nose indicates that cerebrospinal fluid is leaking from the skull 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? o Tissue plasminogen activator (a thrombolytic agent that should dissolve the blood clot that caused the stroke) o Recombinant factor VIII o Nitroglycerin o Lidocaine A nurse is assessing a client who has rheumatoid arthritis. Which of the following assessment findings should the nurse expect? o Unilateral joint involvement o Ulnar deviation (the inflammation that occurs in the hand joints can make them susceptible to deformity from daily use. Ulnar deviation or lateral deviation of the fingers, can occur from opening jars and other similar motions) o Fractures of the spine o Decreased sedimentation rate 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 clients pain? o Clients vital sign changes o Clients report of the type of pain o Clients nonverbal communication o Clients report of pain on a pain scale