Question 1

A client with a left leg fracture is to be taught the three-point gait before discharge. Which instruction should the nurse give to this client?

Accepted Answer

In the three-point gait, both crutches and the affected "bad" leg and foot move together, with the unaffected "good" leg and foot following. Choices A and B are incorrect because the crutches are moved simultaneously, not independently. Choice C is incorrect because the client should not bear weight on the fractured leg when using the three-point gait.

Question 2

The nurse is encouraging a client who has undergone an amputation to immediately fit a prosthesis. The advantage for this immediate action is:

Accepted Answer

When the prosthesis is in place immediately following surgery, the client can stand up several hours postoperatively and walk the next day. The operative site is closed to outside contamination and benefits from improved circulation due to ambulation.

Question 3

While installing Christmas lights on his rooftop, Matt fell from the staircase and sustained a fractured femur. He was placed in a balance skeletal traction with a Thomas splint. To prevent pressure points from occurring around the top of the splint, the most important intervention is to:

Accepted Answer

The most important intervention for preventing pressure points is to keep the client pulled up in bed. The nurse may also pad the top of the splint with soft material, such as cotton wadding, to prevent excoriation. The footplate would prevent foot drop.

Question 4

Two weeks after a cast is applied, a foul odor is detected at the lower end of the cast. A window is made in the cast over the infected area and an antibiotic is prescribed. After 3 days on antibiotic therapy, which effect would be most indicative of a therapeutic response?

Accepted Answer

The most objective measure of the effectiveness of an antibiotic is a return of the white blood cell count to normal (WBC: 5,000-10,000/mm3). A low-grade temperature (Choice B) may indicate a lingering infection. No complaints of pain and a good appetite (Choices C and D) are both good clinical indicators, but not as objective or as clearly measurable as the white blood cell count.

Question 5

Stimson, age 59 years old, had a total left hip replacement after a bathroom accident. The doctor orders for a possible discharge the day after tomorrow. Discharge teaching for Mr. Stimson should include:

Accepted Answer

A raised toilet seat helps client with a total hip replacement to avoid hyperflexion of the hip joint. Choice B is incorrect because although enoxaparin is an anticoagulant intended to prevent thrombus formation, daily monitoring of coagulation studies is not required with this drug. Choice C is incorrect because jogging would be too much impact and stress on the new hip joint; quadriceps strengthening can be accomplished with other exercises that are not contraindicated. Choice D is incorrect because the client with a new hip joint should avoid hip flexion to or beyond 90°. Adduction, or crossing the affected limb over the center of the body, is also contraindicated and can result in dislocation of the new joint.

Question 6

A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse's response is based on the understanding that this could result in:

Accepted Answer

Crutches are measured so that the tops are two to three finger-widths from the axilla. This ensures that the client's axilla are not resting on the crutch or bearing the weight of the crutch, which could result in injury to the nerves of the brachial plexus.

Question 7

A client is awaiting surgery for reduction of a fractured right femur. Skeletal traction has been applied. Which nursing diagnosis requires the nurse to function collaboratively to achieve the best outcome for the client?

Accepted Answer

Pain management requires the nurse and physician to collaborate to achieve optimal relief for the client, i.e., analgesics as prescribed by the physician and the nurse to monitor the client's response to drug therapy and alert the MD to needed changes. Choices A and C are manageable by independent nursing actions-careful assessment, ROM, and proper positioning. Choice D is not a nursing diagnosis, but a medical problem to be corrected by surgery.

Question 8

Booth, age 48 years old, is undergoing rehabilitation after experiencing a thrombotic stroke. The stroke has developed a residual hemiparesis of Mr. Booth's right side. The nurse caring for Mr. Booth reinforces occupational therapy recommendations by placing items for personal hygiene:

Accepted Answer

Hemiparesis is a one-sided weakness that often occurs following stroke. The client will have maximum return of function and the least amount of frustration with relearning new tasks when objects are placed within easy reach on the unaffected side. This will also decrease the risk for client injury because the client will not have to reach for objects needed for self-care. Unilateral neglect is not a problem when the client has right-sided deficits, so objects do not need to be placed on the affected side.

Question 9

Catherine, a 22-year-old equestrian, obtained a spinal cord injury after she fell off from her horse during a routine practice. The nurse caring for her is aware that she is at risk for developing autonomic dysreflexia. The nurse would carefully monitor for which of the following manifestations?

Accepted Answer

Autonomic dysreflexia can be assessed by noting the presence of severe, throbbing headache, flushed face and neck, bradycardia, and severe hypertension that is sudden in onset. Other signs to assess for are nausea, sweating, nasal stuffiness, and blurred vision. Clients who have a spinal cord injury above the level of T7 are at risk for an exaggerated autonomous response to noxious stimulus.

Question 10

A client newly diagnosed with trigeminal neuralgia asks the nurse to explain why it hurts so much when an episode occurs. The nurse would explain that the pain of trigeminal neuralgia is the result of which of the following?

Accepted Answer

The pain of trigeminal neuralgia is triggered by stimulation of the sensory fibers of the trigeminal nerve. Examples of pressure-related triggering events include shaving, brushing the teeth, washing the face, and eating or drinking. Examples of temperature-related triggers include environmental changes and hot or cold food and drink. The other options listed do not initiate pain of this disorder.

Question 11

Lambert, 68 years old, is admitted for a recent onset (less than 2 hours) of left hemiparesis, facial droop, field cut, and an imaging report indicating a positive computed tomography (CT) scan of the head. The nurse knows that this indicates:

Accepted Answer

A positive CT of the head indicates hemorrhage. A thrombolytic agent is contraindicated in hemorrhage because it causes bleeding, increases the size of the hemorrhagic brain attack, and can cause death. An ischemic brain attack would not be visualized on a CT scan until approximately 12-24 hours after the initial brain injury, when the infarcted and ischemic tissues can be visualized as gray-colored changes on the brain scan.

Question 12

A client with myasthenia gravis is given a Tensilon test. Forty minutes after the test, the client develops severe weakness and ptosis. The nurse should be prepared to:

Accepted Answer

Developing severe weakness within 1 hour of the administration of Tensilon indicates a cholinergic crisis, or overdose of anticholinesterase drugs. The antidote for cholinergic crisis is atropine. Choice B is incorrect because it would be inappropriate to administer an anticholinesterase drug, such as pyridostigmine, to a client in cholinergic crisis. Choice C is incorrect because checking for constricted pupils does not provide useful information. Pupil constriction does not occur during a cholinergic crisis. Choice D is incorrect because intubation is not the first action. Atropine should be used first to counteract the toxic effects of the anticholinesterase drug.

Question 13

Kevin, 23 years old, was admitted for closed head injury following a motor vehicle accident. Which of the following interventions should the nurse plan that would minimize increased intracranial pressure?

Accepted Answer

Positioning the client to maintain the head and neck alignment will facilitate cerebral spinal fluid drainage and prevent increased intracranial pressure due to impediment of spinal fluid drainage.
The head of bed should be elevated greater than or equal to 30 degrees (Choice A), unless specifically ordered otherwise by the physician. Grouping multiple nursing activities (Choice B) like turning, bathing, linen change, and suctioning will dramatically increase intracranial pressure for an extended amount of time. To minimize increase in intracranial pressure, nursing activities should be planned to give the client 30-60 minute breaks between activities. The intracranial pressure will increase with any activity, but the pressure will have an opportunity to decrease to safer levels if activities are not clustered. Positioning to prevent an increase in intracranial pressure is focused on alignment of the head and neck and elevation of the head of bed at 30 degrees, not the legs (Choice D).

Question 14

Martha, a 33-year-old school teacher, is admitted to the unit with symmetrical weakness of lower extremities. After testing, the physician's diagnosis is Guillain-Barre syndrome. The pathophysiologic mechanism of this condition is:

Accepted Answer

The pathologic change that occurs in Guillain-Barre is the destruction of the myelin sheath that coats the axon of the peripheral nerves. Demyelination results in poor impulse conduction along neurons resulting in symmetrical muscle weakness that begins in the lower extremities and ascends to the upper extremities, torso, and then cranial nerves.

Question 15

Gregory, a 55-year-old tailor, is admitted to the hospital complaining of difficulty holding objects. He states that his condition progressively worsened. Based on the initial examination, the physician suspects Amyotrophic Lateral Sclerosis (ALS). The nurse is aware that characteristics of ALS are the following except:

Accepted Answer

Bowel and bladder control of the client remains intact until the end, together with cognition and sensory functions. ALS is a progressive degenerative disease involving the motor neurons of the anterior horn cells, brain stem, and cerebral cortex. It is mainly characterized by weakness and wasting of involved muscles.

Question 16

The appropriate nursing action for a client experiencing expressive aphasia following a brain attack would be to:

Accepted Answer

The client needs an opportunity to receive word images. Point to the object and clearly enunciate its name. Also, the client with expressive aphasia needs the chance to practice repeating words. To consider the impairment permanent would be premature. Waiting may increase the client's frustration. Try to anticipate the client's needs to reduce feelings of helplessness. The nurse plays an important part in showing the family members how to communicate and in not discouraging communication.

Question 17

A client diagnosed with cerebral thrombosis is scheduled for cerebral angiography. Nursing care of the client includes the following except:

Accepted Answer

Keep the extremity used as puncture site flexed to prevent bleeding.
Angiography involves the threading of a catheter through an artery, which can cause trauma to the endothelial lining of the blood vessel. The platelets are attracted to the area causing thrombi formation. This is further enhanced by the slowing of blood flow caused by flexion of the affected extremity. The affected extremity must be kept straight and immobilized during the duration of the bed rest after the procedure. Ice bag can be applied intermittently to the puncture site.

Question 18

A client had a laminectomy and spinal fusion yesterday. Which statement is to be excluded from your plan of care?

Accepted Answer

Before log rolling, remove the pillow from under the client's head and use no pillows between the client's legs. Following a laminectomy and spinal fusion, it is important that the back of the patient be maintained in straight alignment and to support the entire vertebral column to promote complete healing.

Question 19

The physician orders non-weight bearing with crutches for Joy, who had surgery for a fractured hip. The most important activity to facilitate walking with crutches before ambulation begun is:

Accepted Answer

Exercising the triceps, finger flexors, and elbow extensor. These sets of muscles are used when walking with crutches and therefore, need strengthening prior to ambulation.

Question 20

Helen, a client with myasthenia gravis, begins to experience increased difficulty in swallowing. To prevent aspiration of food, the nursing action that would be most effective would be to:

Accepted Answer

Coordinate her meal schedule with the peak effect of her medication, Mestinon. Dysphagia should be minimized during peak effect of Mestinon, thereby decreasing the probability of aspiration. Mestinon can increase her muscle strength, including her ability to swallow.

Quiz 6: Neuro-Muscular