with Verified Answers
The nurse is teaching the client with myasthenia gravis about prevention of myasthenic and
cholinergic crises. The nurse tells the client that this is most effectively done by which
activity? - Ans -Taking medications on time to maintain therapeutic blood levels
A thymectomy via a median sternotomy approach is performed on a client with a diagnosis
of myasthenia gravis. The nurse has assisted in developing a plan of care for the client and
includes which nursing action in the plan? - Ans -Monitor the chest tube drainage.
The nurse is caring for a client with a diagnosis of multiple sclerosis who has been
prescribed oxybutynin (Ditropan). The nurse evaluates the effectiveness of the medication
by asking the client which question? - Ans -"Are you getting up at night to urinate?"
The nurse caring for a client following a craniotomy monitors for signs of increased
intracranial pressure (ICP). Which indicates an early sign of increased ICP? - Ans -
Confusion
A client who sustained a closed head injury has a new onset of copious urinary output.
Urine output for the previous 8-hour shift was 3300 mL, and 2800 mL for the shift before
that. The findings have been reported to the health care provider, and the nurse anticipates
a prescription for which medication? - Ans -Desmopressin (DDAVP)
A client with myasthenia gravis is experiencing prolonged periods of weakness. The health
care provider prescribes a test dose of edrophonium (Enlon) and the client becomes
weaker. The nurse interprets this outcome as indicative of which result? - Ans -
Cholinergic crisis
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,The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least
appropriate measure to minimize the risk of autonomic dysreflexia is which action? -
Ans -Limiting bladder catheterization to once every 12 hours
A halo vest is applied to a client following a cervical spine fracture. The nurse reinforces
instructions to the client regarding safety measures related to the vest. Which statement by
the client indicates a need for further teaching? - Ans -"I will bend at the waist,
keeping the halo vest straight to pick up items."
The nurse is monitoring a client who sustained a head injury and suspects that the client
has a skull fracture. This conclusion is based on which findings? Select all that apply. -
Ans -Drainage from ear
Bruising around the eyes
Pink-tinged drainage from the nose
The nurse is collecting neurological data on an unconscious client. On application of a
central noxious stimulus, the nurse observes this response. How should the nurse
document this response on the client's record? Refer to figure. - Ans -Client
demonstrated decerebrate posturing.
A client with spinal cord injury has experienced more than one episode of autonomic
dysreflexia. The nurse should avoid which action that could trigger an episode of this
complication? - Ans -Allowing the client's bladder to become distended
A client with Parkinson's disease is embarrassed about the symptoms of the disorder and
is bored and lonely. The nurse should plan which approach as therapeutic in assisting the
client to cope with the disease? - Ans -Encourage and praise perseverance in
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exercising and performing ADL.
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, A client with a T4 spinal cord injury is to be monitored for autonomic dysreflexia
(hyperreflexia). Which finding is indicative of this complication? - Ans -The client
complains of a headache, and the blood pressure is elevated.
The nurse is monitoring a client with a C5 spinal cord injury for spinal shock. Which
findings would be associated with spinal shock in this client? Select all that apply. -
Ans -Bowel sounds are absent.
The client's abdomen is distended.
Respiratory excursion is diminished.
Accessory muscles of respiration are areflexic.
Acetazolamide is prescribed for a client with a diagnosis of a supratentorial lesion. The
nurse monitors the client for effectiveness of this medication, knowing which is its primary
action? - Ans -Decrease cerebrospinal fluid production
The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse
determines that this is cerebrospinal fluid (CSF) if the fluid meets which criteria? -
Ans -Separates into concentric rings and tests positive for glucose
The family of an unconscious client with increased intracranial pressure is talking at the
client's bedside. They are discussing the gravity of the client's condition and wondering if
the client will ever recover. How should the nurse interpret the client's situation? -
Ans -It is possible the client can hear the family.
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