RN Med Surg Neurosensory & Musculoskeletal Exam Questions And Answers (Verified)

RN Med Surg Neurosensory & Musculoskeletal Exam Questions And Answers (Verified) A nurse is assessing a client who is quadriplegic following a cervical fracture at vertebral level C5. The client reports a throbbing headache and nausea. The nurse notes flushing and a blood pressure of 220/110 mm Hg. Which of the following actions should the nurse take first? Elevate the head of the client's bed Explanation: This client is experiencing autonomic dysreflexia and is at risk for cerebral vessel rupture or increased intracranial pressure. Move the client from supine to an upright position. A nurse is caring for a client who is in balanced suspension skeletal traction and reports intermittent muscle spasms. Which of the following actions should the nurse take first? Check the position of the weights and ropes Explanation: The nurse should check the weights and ropes to see what is the cause of the muscles spasms. A nurse in an emergency department is caring for a client who suddenly lost consciousness and fell while at home. The provider determines that the client had an embolic stroke. Which of the following medications should the nurse expect to administer? Tissue plasminogen activator Explanation: This is a thrombolytic agent that dissolves the clot that caused the stroke. 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 client's pain? Client's report of pain on a pain scale Explanation: Remember the pain is whatever the client says it is. To get an ACCURATE pain rating you use the pain scale first and back it up with any identifiers like grimacing/moaning, etc. A nurse is caring for a client who is recovering from a stroke and has right-sided homonymous hemianopsia. To help the client adapt to the hemianopsia, the nurse should take which of the following actions? Remind the client to look consciously at both sides of their meal tray Explanation: Homonymous hemianopsia is a condition due to injury of a part of the brain that disrupts the visual field. It allows the person to only see either to their left or right side. So reminding them to look at their whole tray is accurate for this scenario because they might eat the food they can see only. A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect?