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A client with multiple sclerosis is experiencing muscle weakness and an
ataxic gait. The nurse identifies impaired physical mobility as a nursing
diagnosis. Which intervention is most appropriate?
A. Encourage complete bed rest during periods of weakness
B. Assist the client with range-of-motion exercises every 8 hours
C. Restrict fluid intake to reduce muscle fatigue
D. Encourage the client to avoid all physical activity
Answer: B. Assist the client with range-of-motion exercises every 8
hours
Rationale: Regular range-of-motion exercises help maintain joint
mobility, muscle flexibility, and functional ability in clients with
multiple sclerosis. Prolonged inactivity can worsen weakness, stiffness,
and contracture formation. Exercise should be individualized
according to the client's tolerance.
A client with a severe head injury is observed with the arms flexed
toward the chest and the legs extended. Which type of posturing is the
nurse observing?
A. Decerebrate posturing
B. Flaccid posturing
,C. Decorticate posturing
D. Spastic posturing
Answer: C. Decorticate posturing
Rationale: Decorticate posturing is characterized by flexion of the arms
toward the chest with extension of the lower extremities. It indicates
significant neurologic injury. Decerebrate posturing is characterized by
extension and external rotation of the upper extremities and is
generally associated with more severe brainstem dysfunction.
A client with a brain tumor reports a headache that is most severe upon
awakening. Which nursing intervention should the nurse perform first?
A. Elevate the head of the bed
B. Encourage the client to ambulate
C. Place the client in a flat supine position
D. Encourage forceful coughing
Answer: A. Elevate the head of the bed
Rationale: Elevating the head of the bed promotes venous drainage
from the brain and can help decrease intracranial pressure. Morning
headaches may occur with increased intracranial pressure because
carbon dioxide retention and changes in cerebral blood flow can occur
during sleep.
A client receiving oxygen therapy is scheduled for magnetic resonance
imaging. Which nursing action is essential for safety?
A. Increase the oxygen flow rate before entering the MRI room
B. Place the oxygen cylinder beside the MRI machine
,C. Secure all metal equipment to the client's bed
D. Ensure that equipment containing metal does not enter the MRI
room
Answer: D. Ensure that equipment containing metal does not enter the
MRI room
Rationale: MRI uses a powerful magnetic field. Ferromagnetic objects
can become dangerous projectiles and can interfere with the
examination. Only MRI-compatible equipment should enter the MRI
environment.
A client with head trauma is being cared for in the emergency
department. A nursing assistant is instructed to clean the client's face
and torso. Which action by the nursing assistant requires immediate
correction?
A. Cleaning the client's face gently
B. Moving the client's head to clean behind the ears
C. Cleaning the torso while maintaining spinal alignment
D. Reporting skin abnormalities to the nurse
Answer: B. Moving the client's head to clean behind the ears
Rationale: A client with significant head trauma may also have a
cervical spine injury. The head and neck should be maintained in
neutral alignment until spinal injury has been ruled out. Unnecessary
movement can worsen an unstable cervical injury.
A client sustains a head injury followed by changes in personality and
affect. Which brain structure should the nurse suspect is affected?
, A. Frontal lobe
B. Occipital lobe
C. Cerebellum
D. Medulla oblongata
Answer: A. Frontal lobe
Rationale: The frontal lobe is involved in judgment, personality,
behavior, executive function, concentration, and emotional regulation.
Injury to this area can produce significant changes in personality and
affect.
A client has damage to Broca's area in the left frontal lobe. Which
function should the nurse assess?
A. Hearing
B. Balance
C. Speech production
D. Visual recognition
Answer: C. Speech production
Rationale: Broca's area is responsible primarily for expressive
language and the motor production of speech. Damage can result in
expressive aphasia, in which the client has difficulty producing
understandable speech despite relatively preserved comprehension.
A client reports difficulty maintaining balance and controlling fine
movements. Which area of the brain should the nurse expect the
provider to evaluate?