ATI Homework 18 - Cognition and Sensation Detailed Answer Key

1. A nurse notes a client who has Parkinson disease shows signs of dyskinesia. Which of the following physical manifestations should the nurse expect? A. Difficulty swallowing Rationale: The nurse should expect to find with signs of dyskinesia difficulty moving, not swallowing. B. Difficulty speaking Rationale: The nurse should expect to find with signs of dyskinesia difficulty moving, not speaking. C. Difficulty moving Rationale: The nurse should expect to find with signs of dyskinesia difficulty moving which is correct. D. Difficulty breathing Rationale: The nurse should expect to find with signs of dyskinesia difficulty moving not breathing. 2. A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is appropriate for the nurse to take? (Select all that apply.) A. Administer the client's PRN pain medication. B. Darken the client's room and close the door. C. Limit the client's fluid intake for 8 hr. D. Keep the client flat in bed for several hours. Rationale: Administer the client's PRN pain medication is correct. This action is an appropriate nursing action for management of a post-lumbar puncture headache.Darken the client's room and close the door is correct. This is an appropriate nursing action for management of a post-lumbar puncture headache.Limit the client's fluid intake for 8 hr is incorrect. Increasing fluids is helpful in replacing the cerebrospinal fluid that was removed during the procedure, unless contraindicated.Keep the client flat in bed for several hours is correct. The headache is usually relieved when the client lies down, keeping the client flat in bed for several hours should relieve the headache. 3. A nurse is reinforcing the discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate? A. “Wear an eye patch on the right eye at all times.” Rationale: The nurse should instruct the client to alternate every two hours an eye patch to improve diplopia, not leave on the right eye continually. B. “Plan to relax in a hot tub spa each day.” Rationale: The nurse should instruct the client to avoid extreme temperature changes which may exacerbate the MS symptoms. C. “Engage in a vigorous exercise program.” Rationale: The nurse should instruct the client to develop a tolerable exercise program, not a vigorous exercise program, which may exacerbate the MS symptoms. D. “Implement a schedule to include periods of rest.” Rationale: The nurse should implement a schedule with periods of exercise followed by periods of rest to maintain muscle strength and coordination. 4. A nurse is caring for a client who has undergone a cataract removal of the left eye with placement of an intraocular lens implant. Which of the following statements by the client indicates to the nurse that additional education is needed? A. “Even though my vision is improved, I will still need glasses.” Rationale: Most clients will still need glasses because the intraocular lens implant does not restore a client's vision to 20/20. B. “If there is drainage around my eye, I should wipe it away with a clean, damp washcloth.” Rationale: Drainage is a normal response to the operative procedure and may be removed with a clean, damp washcloth. C. “I may have pain for a day or two, but keeping the operated eye patched will help.” Rationale: The client should not keep the operated eye patched. D. “My vision may be blurry for a couple weeks until my eye has completely healed.” Rationale: Blurred vision is to be expected until the eye has healed and the client is fitted with corrective glasses. 5. A nurse is caring for a client following a craniotomy. In report the charge nurse informs the nurse that the client is at risk for diabetes insipidus. Which of the following findings is consistent with this diagnosis? A. Hypertension Rationale: Hypotension is a manifestation of diabetes insipidus. B. Elevated blood glucose Rationale: Elevated blood glucose is not a manifestation of diabetes insipidus. C. Increased urine output Rationale: Diabetes insipidus is a water metabolism disorder caused by a deficiency of antidiuretic hormone (ADH). This deficiency results in the excretion of large amounts of dilute urine. Dehydration and shock may ensue, resulting in a life threatening situation. D. Fluid retention Rationale: Fluid loss is a manifestation of diabetes insipidus.