Deck 6: Neuro-Muscular

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?

A)"Advance your right crutch, swing the left foot forward, advance the left crutch, and then bring the right foot forward."
B)"Move your right crutch and left foot forward together, and then swing the right foot and left crutch in one movement."
C)"While partially bearing weight on your left leg, advance both crutches and then bring your right leg forward."
D)"Using one movement, advance your left foot and both crutches and then bring right leg forward."

Answer 1

"Using one movement, advance your left foot and both crutches and then bring right leg forward."

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:

A)Ability to ambulate sooner
B)Less chance of phantom limb sensation
C)Dressing changes are not necessary
D)Better fit of the prosthesis

Answer 2

Ability to ambulate sooner

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:

A)Protect the skin with lotion
B)Keep the client pulled up in bed
C)Pad the top of the splint with washcloths
D)Provide a footplate in the bed

Answer 3

Keep the client pulled up in bed

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?

A)WBC is 7,900/mm3
B)Temperature is 99.4°F
C)No complaints of pain
D)Appetite is fairly good

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:

A)Use of a raised toilet seat
B)Daily monitoring of coagulation status if the client will be self-administering enoxaparin at home
C)A gentle program of jogging to strengthen the quadriceps muscles
D)Active range of motion exercises that include 90° flexion at the hip

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:

A)A fall and further injury
B)Injury to the brachia plexus nerves
C)Skin breakdown in the area of the axilla
D)Impaired range of motion while the client ambulates

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?

A)Risk for impaired skin integrity
B)Pain (acute)
C)Impaired physical mobility
D)Risk for fracture deformity

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:

A)On the overbed table on the right side
B)On the overbed table on the left side
C)One foot away from the bed on the right side
D)One foot away from the bed on the left 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?

A)Tachycardia
B)Hypotension
C)Severe, throbbing headache
D)Cyanosis of the head and neck

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?

A)Stimulation of the nerve by temperature or pressure
B)Irritation due to cellular effects of hypoglycemia
C)Release of epinephrine during the fight-or-flight response
D)An immune system reaction to cold and influenza

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:

A)A hemorrhagic brain attack. The client should receive a thrombolytic agent.
B)An ischemic brain attack. The client should have a thrombolytic agent.
C)A hemorrhagic brain attack. The client should not receive a thrombolytic agent.
D)An ischemic brain attack. The client should not receive a thrombolytic agent.

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:

A)Administer atropine
B)Administer pyridostigmine
C)Check for constricted pupils
D)Intubate the client

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?

A)Maintain head of the bead at less than 10 degrees
B)Group all nursing activities and leave the client undisturbed for 2 hours
C)Maintain alignment of the head and neck
D)Elevate the client's legs

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:

A)Demyelination and degeneration of the myelin sheath
B)Pigmented neuron loss
C)Defective impulse transmission between nerve and muscle cells
D)An unexplained loss of basal ganglia cells

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:

A)Loss of bowel and urine control
B)Uncontrolled outburst of crying
C)Aphagia and dysarthria
D)Fasciculation of the involved muscles

Question 16

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

A)Help the client and family accept the permanent disability
B)Associate words with physical objects
C)Wait indefinitely for client to verbalize
D)Tell the family that the client cannot communicate

Question 17

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

A)Inform the client that a warm, flushed feeling and a salty taste may be felt
B)Maintain pressure dressing over the site of puncture and check for bleeding
C)Check pulse, color, and temperature of the extremity distal to the site of puncture site
D)Keep the extremity used as puncture site flexed to prevent bleeding

Question 18

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

A)Before log rolling, place a pillow under the client's head and a pillow between the client's legs.
B)Before log rolling, remove the pillow from under the client's head and use no pillows between the client's legs.
C)Keep the knees slightly flexed while the client is lying in a semi-Fowler's position in bed.
D)Keep a pillow under the client's head as needed for comfort.

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:

A)Exercising the triceps, finger flexors, and elbow extensors
B)Sitting up at the edge of the bed to help strengthen back muscles
C)Doing isometric exercises on the unaffected leg
D)Using the trapeze frequently for pull-ups to strengthen the bicep muscles

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:

A)Change her diet order from soft foods to clear liquids
B)Place an emergency tracheostomy set in her room
C)Assess her respiratory status before and after meals
D)Coordinate her meal schedule with the peak effect of her medication, Mestinon