RN TARGETED MEDICAL SURGICALNEUROSENSORY AND MUSCULOSKELETAL<\/p>\n\n\n\n
A nurse us 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? – ANSWER\u0002Check the position of the weights and ropes
Rationale: The first action the nurse should take when using the
nursing process is to assess the client. The nurse should first
check the position of the weights and ropes to investigate the
cause of the muscle spasms. The weights might be too heavy, or
the nurse might need to realign the client.
A nurse is caring for a client who is 72 hr postoperative
following an above the knee amputation and reports phantom
limb pain. Which of the following actions should the nurse take?<\/p>\n\n\n\n
Gabapentin is an oral antiepileptic medication that is effective
for treating sharp, burning, phantom limb pain.
A nurse us caring for a client who has a spastic bladder
following a spinal cord injury. Which of the following action
should the nurse take to help stimulate micturition? – ANSWER\u0002Stroke the clients inner thigh
Rationale: The nurse should stimulate micturition by stroking
the client’s inner thigh. Other techniques include pinching the
skin above the groin and providing digital anal stimulation.
A nurse is assessing a client who had a right hemispheric stroke.
Which of the following neurologic deficits should the nurse
expect? – ANSWER- Impulsive behavior
Rationale: The nurse should expect clients who had a right
hemispheric stroke to demonstrate impulsive behavior, poor
judgment, and lack of awareness of neurologic deficits.
A nurse is assessing a client who has a head injury following a
motor vehicle crash. The nurse should identify which of the
following indicated increasing intracranial pressure? –
ANSWER- Restlessness<\/p>\n\n\n\n
Rationale: Behavioral changes, such as restlessness and
irritability, are early manifestations of increased intracranial
pressure.
A nurse in an emergency department is caring for a client who
suddenly lost consciousness and fell at home. The provider
determines that the client had an embolic stroke. Which of the
following medications should the nurse expect to administer –
ANSWER- Tissue plasminogen activator
Rationale: Tissue plasminogen activator is a thrombolytic agent
that should dissolve the blood clot that caused the stroke.
A nurse is caring for a client who has retinal detachment. Which
of the following findings should the nurse expect? – ANSWER\u0002Flashes of bright light
Rationale: The nurse should expect a client who has a retinal
detachment to see flashes of bright light or floating dark spots in
the affected eye as the retinal layers separate.
A nurse is caring for a client who has a history of a status
epilepticus ad requires seizure precautions. Which of the the
following actions should the nurse take – ANSWER- Establish
IV access<\/p>\n\n\n\n