Sei sulla pagina 1di 2

Per Buddy : pls answer lengthwise - TO BE SUBMITTED 8PM 2/22/15

Omar Christian Tuazon - got copy to be flash sa projector incase

1. A client with amyotrophic lateral sclerosis (ALS) tells the nurse, "Sometimes I feel so frustrated. I can't do anything
without help!" This comment best supports what nursing diagnosis?
2. When caring for a client with a head injury, the nurse must stay alert for signs and symptoms of increased
intracranial pressure (ICP). What cardiovascular findings are late indicators of increased ICP?
3. When caring for a client with head trauma, the nurse notes a small amount of clear, watery fluid oozing from the
client's nose. What should the nurse do?
4. Damage to which area of the brain results in receptive aphasia?
5. A client is admitted to an acute care facility for treatment of a brain tumor. When reviewing the chart, the nurse
notes that the client's extremity muscle strength is rated 1/5. What does this mean?
6. A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours.
The average catheterized urine volume has been 550 ml. The nurse should plan to:
7. The nurse is planning care for a client with multiple sclerosis. What problems should the nurse expect the client to
8. A client undergoes cerebral angiography to evaluate for neurologic deficits. Afterward, the nurse checks frequently
for signs and symptoms of complications associated with this procedure. What findings indicate spasm or occlusion of
a cerebral vessel by a clot?
9. The nurse is administering neostigmine to a client with myasthenia gravis. What nursing intervention should the
nurse implement?
10. A 78-year-old Alzheimer's client is being treated for malnutrition and dehydration. The nurse decides to place him
closer to the nurses' station because of his tendency to:
11. How should the nurse position a client for a lumbar puncture?
12. A client with Guillain-Barr syndrome has paralysis affecting the respiratory muscles and requires mechanical
ventilation. What should the nurse tell the client about the paralysis?
13. The nurse is caring for a client in a coma who has suffered a closed head injury. What intervention should the
nurse implement to prevent increases in intracranial pressure (ICP)?
14. When obtaining the vital signs of a client with multiple traumatic injuries, the nurse detects bradycardia,
bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may
reflect which complication?
15. A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's
care, the nurse should assign highest priority to what nursing diagnosis?
16. The nurse is performing a mental status examination on a client diagnosed with a subdural hematoma. This test
assesses what possible functions?
17. After a motor vehicle accident, a client is admitted to the medical-surgical unit with a cervical collar in place. The
cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury.
Until such an injury is ruled out, the nurse should restrict this client to which position?
18. The nurse is caring for a client with an acute bleeding cerebral aneurysm. The nurse should take all of the
following steps except:
19. A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:
20. The nurse is caring for an elderly client who exhibits signs of dementia.
21. The nurse is observing a client with cerebral edema for evidence of increasing intracranial pressure. She monitors
his blood pressure for signs of widening pulse pressure. His current blood pressure is 170/80 mm Hg. What is the
client's pulse pressure?
22. After striking his head on a tree while falling from a ladder, a young man is admitted to the emergency
department. He's unconscious and his pupils are nonreactive. What intervention would be the most dangerous for the
23. A client is transferred to the intensive care unit after evacuation of a subdural hematoma. What nursing

intervention would reduce the client's risk of increased intracranial pressure (ICP)?
24. A client is hospitalized with Guillain-Barr syndrome. What data collection finding is most significant?
25. During recovery from a stroke, a client is given nothing by mouth, to help prevent aspiration. To determine when
the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once each shift. This assessment
26. The nurse is teaching a client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse
should tell the client to:
27. A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is
confirmed by:
28. The nurse is collecting data on a 38-year-old client diagnosed with multiple sclerosis. What are following
symptoms would the nurse expect to find?
29. A client is admitted in a disoriented and restless state after sustaining a concussion from a car accident. What
nursing diagnosis takes highest priority in this client's plan of care?
30. A client with quadriplegia is in spinal shock. What should the nurse expect?