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The nurse is caring for a client who begins to experience seizure activity while
in bed. Which actions would the nurse take? *Select all that apply.*
1.Loosening restrictive clothing
2.Restraining the client's limbs
3.Removing the pillow and raising padded side rails
4.Positioning the client to the side, if possible, with the head flexed forward
5.Keeping the curtain around the client and the room door open so that when
help arrives, they can quickly enter to assist Answer - 1.Loosening restrictive
clothing
3.Removing the pillow and raising padded side rails
4.Positioning the client to the side, if possible, with the head flexed forward
The nurse is assigned to care for a client with complete right-sided hemiparesis
from a stroke (brain attack). Which characteristics are associated with this
condition? *Select all that apply.*
1.The client is aphasic
2.The client has weakness on the right side of the body
3.The client has complete bilateral paralysis of the arms and legs
4.The client has weakness on the right side of the face and tongue
5.The client has lost the ability to move the right arm but is able to walk
independently
,6.The client has lost the ability to ambulate independently but is able to feed
and bath self without assistance Answer - 1.The client is aphasic
2.The client has weakness on the right side of the body
4.The client has weakness on the right side of the face and tongue
The nurse is assessing the adaptation of a client to changes in functional status
after a stroke (brain attack). Which observation indicates to the nurse that the
client is adapting most successfully?
1.Gets angry with family if they interrupt
2.Experiences bouts of depression and irritability
3.Has difficulty with using modified feeding utensils
4.Consistently uses adaptive equipment in dressing self Answer -
4.Consistently uses adaptive equipment in dressing self
The nurse is teaching a client with myasthenia gravis about the prevention of
myasthenic and cholinergic crises. Which client activity suggests that teaching
is most effective?
1.Taking medications as scheduled
2.Eating large, well-balanced meals
3.Doing muscle-strengthening exercises
4.Doing all chores early in the day while less fatigued Answer - 1.Taking
medications as scheduled
The nurse is instructing a client with Parkinson's Disease about preventing falls.
Which client statement reflects a need for further teaching?
1."I can sit down to put on my pants and shoes."
2."I try to exercise every day and rest when I'm tired."
3."My son removed all loose rugs from my bedroom."
, 4."I don't need to use my walker to get to the bathroom." Answer - 4."I don't
need to use my walker to get to the bathroom."
The client is admitted to the hospital with a diagnosis of Guillain-Barré
syndrome. Which past medical history finding makes the client most at risk for
this disease?
1.Meningitis or encephalitis during the last 5 years
2.Seizures or trauma to the brain within the last year
3.Back injury or trauma to the spinal cord during the last 2 years
4.Respiratory or gastrointestinal infection during the previous month Answer -
4.Respiratory or gastrointestinal infection during the previous month
A client with Guillain-Barré syndrome has ascending paralysis and is intubated
and receiving mechanical ventilation. Which strategy would the nurse
incorporate in the plan of care to help the client cope with this illness?
1.Giving client full control over care decisions and restricting visitors
2.Providing positive feedback and encouraging active range of motion
3.Providing information, giving positive feedback, and encouraging relaxation
4.Providing intravenously administered sedatives, reducing distractions, and
limiting visitors Answer - 3.Providing information, giving positive feedback, and
encouraging relaxation
The nurse is instituting seizure precautions for a client who is being admitted
from the emergency department. Which measures would the nurse include in
planning for the client's safety? *Select all that apply.*
1.Padding the side rails of the bed
2.Placing an airway at the bedside
3.Placing the bed in the high position
4.Putting a padded tongue blade at the head of the bed