ATI Targeted Medical Surgical Neurosensory and
Musculoskeletal Test Challenge with Solutions 2023-2024
A nurse is planning care for a client who has a closed traumatic brain injury from a fall and is
receiving mechanical ventilation. Which of the following intervention is the nurse's priority?
A. Maintain a PaCO2 of approx. 35 mmHg
B. Provide small doses of fentanyl via bolus for pain management
C. Measure body temperature every 1-2hr
Answer: A. Maintain a PaCO2 of approx. 35 mmHg
Rationale:
The greatest risk to this client is injury from increased intracranial pressure. Therefore, the
nurse's priority action is to maintain the PaCO2 at approximately 35 mm Hg to prevent
hypercarbia and subsequent vasodilation effects that lead to increase in intracranial pressure.
A nurse is caring for a client who has a retinal detachment. which of the following findings
should the nurse expect?
A. Photophobia
B. Complete vision loss
C. Flashes of bright light
D. Cloudiness of the lends
Answer: C. Flashes 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.
Photophobia - The nurse should expect photophobia in a client who has a migraine headache.
• Complete vision loss -The nurse should expect a client who has a retinal detachment to have
some visual field loss in the area of the detachment, but complete vision loss is not an expected
finding.
• Cloudiness of the lens- The nurse should expect a client who has cataracts to experience
cloudiness of the lens
A nurse is caring for a client who has a spastic bladder following a spinal cord injury. Which of
the following actions should the nurse take to help stimulate micturition?
A. Encourage the client to use the Valvalsa maneuver
B. Stroke the client's inner thigh
C. Perform the Crede maneuver
D. Administer a diuretic
Answer: B. Stroke the client's 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.
Perform the Credé maneuver. The nurse should apply direct pressure over the client's bladder,
also known as the Credé maneuver, to express urine from a flaccid bladder. It is not effective for
clients who have a spastic bladder due to the spasticity of the external sphincter. Administer a
diuretic. Antispasmodics such as oxybutynin, rather than diuretics, can be effective for treating
mild spastic bladder problems. Encourage the client to use the Valsalva maneuver. -The nurse
should encourage the client to hold their breath and bear down, also known as the Valsalva
maneuver, to express urine from a flaccid bladder. It is not effective for clients who have a
spastic bladder due to the spasticity of the external sphincter.
A nurse is caring for a client who has viral meningitis. Which of the following actions should the
nurse take?
A. Assess the client's neurologic status every 8 hr
B. Initiate droplet precautions
C. Check capillary refill at least every 4 hr
D. Place the client in a well-lit environment
Answer: C. Check
Rationale:
capillary refill at least every 4hr- The nurse should perform a complete vascular assessment at
least every 4 hr to monitor for vascular compromise. Place the client in a well-lit environment.
The nurse should minimize the client's exposure to light from windows and overhead lights
because photophobia, or light sensitivity, is a manifestation of viral meningitis.
Assess the client's neurologic status every 8 hr. The nurse should assess the client's vital signs
and neurologic status at least every 2 to 4 hr. Initiate droplet precautions. The nurse should
implement droplet precautions for clients who have bacterial meningitis. Standard precautions
are sufficient for clients who have viral meningitis.
A nurse is caring for a client who has a history of status epilepticus and requires seizure
precautions. Which of the following actions should the nurse take?
A. Assess hourly for a spike in blood pressure
B. Keep the client on bed rest
C. Keep a padded tongue blade at the bedside
D. Establish IV access
Answer: D. Establish IV access
Rationale:
The nurse should plan to establish IV access with a large-bore catheter and administer 0. 9%
sodium chloride if seizures are imminent. If the client is stable, the nurse should initiate a saline
lock.
Assess hourly for a spike in blood pressure. The nurse should check the client's vital signs and
perform neurological checks after a seizure. However, a change in blood pressure does not
correlate with an increased incidence of seizure activity.
Keep the client on bed rest. A client who is at risk for seizures does not require bed rest.
However, if seizures are imminent or frequent, the nurse should institute safety measures, such
as placing the mattress on the floor or raising the side rails, according to agency policy. Keep a
padded tongue blade at the bedside. my answer, The nurse should not plan to place objects, such
as a padded tongue blade, in the client's mouth during a seizure because it can injure teeth and
put the client at risk for aspirating tooth fragments. The tongue blade could also obstruct the
client's airway.
A nurse is teaching a client and her family about the diagnosis and treatment of Alzheimer's
disease. Which of the following statements should the nurse identify as an indication that the
family understands the teaching?
A. "There is a test for Alzheimer's disease that can establish a reliable diagnosis"
B. "The goal of medication therapy is to reverse the degenerative changes that can occur in brain
tissue"
C. "Early manifestations of Alzheimer's disease include mild tremors and muscular rigidity"
D. "The medications that treat Alzheimer's disease can help delay cognitive changes"
Answer: D. "The medications that treat Alzheimer's disease can help delay cognitive changes"
Rationale:
"Medications that treat Alzheimer's disease enhance the availability of acetylcholine, which can
slow cognitive decline in some clients.
"There is a test for Alzheimer's disease that can establish a reliable diagnosis. “There is no
specific test for identifying Alzheimer's disease, except direct examination of the brain on
autopsy. Providers diagnose Alzheimer's disease based on manifestations and by ruling out other
diseases.
"The goal of medication therapy is to reverse the degenerative changes that can occur in brain
tissue. "None of the medications currently available reverse the course of Alzheimer's disease.
"Early manifestations of Alzheimer's disease include mild tremors and muscular rigidity. "Early
manifestations include short-term memory loss, forgetfulness, and a shortened attention span.
Mild tremors and muscular rigidity are manifestations of Parkinson's disease.
A nurse is assessing a client who has a new diagnosis of osteoarthritis. Which of the following
findings should the nurse expect? (Select all that apply)
A. Crepitus with joint movement
B. Decreased range of motion of the affected joint
C. Low-grade fever
D. Spongy tissue over the joints
E. Joint pain that resolves with rest
Answer: A. Crepitus with joint movement is correct.
Rationale:
Osteoarthritis is a degenerative joint disease. Crepitus, a grating sound, is an expected finding
with clients who have osteoarthritis as loosened bone and cartilage move around in the fluid
inside the joint.
Decreased range of motion of the affected joint is correct. Decreased range of motion is an
expected finding with clients who have osteoarthritis because the client's pain limits movement.
Low-grade fever is incorrect. Osteoarthritis does not cause systemic manifestations. Rheumatoid
arthritis causes many systemic manifestations, including low-grade fever, weakness, anorexia,
and paresthesias.
Spongy tissue over the joints is incorrect. Spongy joint tissue is an expected finding with
rheumatoid arthritis, which is an inflammatory disease, not a degenerative disease.
Joint pain that resolves with rest is correct. Joint pain that resolves with rest is an expected
finding with clients who have osteoarthritis. A client who has osteoarthritis experiences
increased pain with activity and decreased pain with rest.
A nurse is teaching a client who has osteoporosis and has a new prescription for alendronate.
Which of the following information should the nurse include in the teaching?
A. "Take this medication with 8 oz of milk"
B. "Remain upright for 30 min after taking this medication"
C. "Wait 1 hr after taking other medications to take alendronate"
D. "Take vitamin C to promote absorption of this medicaton"
Answer: B. "Remain upright for 30 minutes after taking this medication. "
Rationale:
To prevent esophagitis or esophageal ulcers, which can result from alendronate therapy, the
client should sit upright for 30 min after taking this medication.
"Take this medication with 8 ounces of milk. " The nurse should instruct the client to take
alendronate with 240 mL (8 oz) of water, not milk. Foods or beverages containing calcium can
reduce medication absorption.
"Wait 1 hour after taking other medications to take alendronate. "The nurse should instruct the
client to take alendronate first thing in the morning, at least 30 min before other medications.
"Take vitamin C to promote absorption of this medication. "Vitamin C intake does not increase
alendronate absorption and some sources, such as orange juice, decrease absorption. However,
the nurse should encourage the client to take vitamin D, which promotes calcium absorption.
A nurse is planning care for a client following a lumbar puncture. Which of the following actions
should the nurse plan to take?
A. Apply pressure dressing to the site for 8 hr
B. Restrict the client's fluid intake for 24 hr
C. Ensure that the client lies flat for up to 12 hr
D. Inform the client that neck stiffness is an expected outcome of the procedure
Answer: C. Ensure that the client lies flat for up to 12 hr.
Rationale:
The client should lie flat for up to 12 hr to prevent cerebrospinal fluid leakage from the puncture
site, which can cause a headache
Apply a pressure dressing to the site for 8 hr. The nurse should apply pressure to the site and then
apply an adhesive bandage, not a pressure dressing.
Restrict the client's fluid intake for 24 hr. The client should increase fluid intake to replace the
cerebrospinal fluid the provider removed during the procedure.
Inform the client that neck stiffness is an expected outcome of the procedure.
The nurse should instruct the client to report complications of a lumber puncture such as voiding
difficulties, fever, stiffness of the back or neck, nausea, and vomiting.
A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings
should the nurse expect?
A. Unilateral joint involvement
B. Ulnar deviation
C. Fracture of the spine
D. Decreased sedimentation rate
Answer: B. Ulnar deviation
Rationale:
A client who has rheumatoid arthritis can experience inflammation in the hand joints that can
make them susceptible to deformity from daily use. Ulnar deviation, or lateral deviation of the
fingers, can occur from opening jars and other similar motions. Unilateral joint involvement
Rheumatoid arthritis usually occurs bilaterally and symmetrically. Osteoarthritis usually occurs
unilaterally.
Fractures of the spine Compression fractures of the spine are more common in clients who have
osteoporosis.
Decreased sedimentation rate. A client who has rheumatoid arthritis will have an increased
sedimentation rate due to the body's response to the inflammatory connective tissue disorder.
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?
A. Remind the client that the surgery removed the limb
B. Change the dressing on the client's residual limb
C. Request a prescription for gabapentin for the client
D. Elevate the client's residual limb above the heart level
Answer: C. Request a prescription for gabapentin for the client.
Rationale:
The nurse should request a prescription for a nonopioid medication to help minimize phantom
limb pain. Gabapentin is an oral antiepileptic medication that is effective for treating sharp,
burning, phantom limb pain.
Remind the client that the surgery removed the limb. -It is not therapeutic for the nurse to remind
the client that the limb is gone because it does not address the client's pain.
Change the dressing on the client's residual limb. Changing the dressing on the client's residual
limb does not address the client's pain. Elevate the client's residual limb above heart level.
The nurse should only elevate the client's residual limb above the heart level within the first 48
hr following the surgery. After that time, doing so can cause a hip or knee flexion contracture.
A nurse is developing a teaching plan for a client who has Meniere's disease. Which of the
following instructions should the nurse include?
A. "Move your head slowly to decrease vertigo"
B. "Apply warm packs to the affected ear during acute attacks"
C. "Increase your intake of foods and fluids high in salt"
D. "Take corticosteroid during acute attacks"
Answer: A. "Move your head slowly to decrease vertigo. "
Rationale:
The nurse should instruct the client to use slow head movements to keep from worsening the
vertigo.
"Apply warm packs to the affected ear during acute attacks. "-Applying warm packs to the
affected ear does not relieve the manifestations of Ménière's disease. Helpful interventions
include drinking plenty of water, decreasing salt intake, and not smoking.
"Increase your intake of foods and fluids high in salt. "Clients who have Ménière's disease
should avoid consuming foods and fluids that have a high sodium content because they cause
fluid retention, which exacerbates the manifestations of Ménière's disease.
"Take corticosteroids during acute attacks. "Taking corticosteroids will not relieve the
manifestations of Ménière's disease and can actually worsen them because these medications
cause fluid retention. The client should take an antihistamine, such as meclizine, to minimize or
stop the attack.
A nurse is reviewing postoperative instructions with a client following cataract surgery. Which of
the following client statements indicates an understanding of the instructions?
A. "I should call my doctor if my vision gets worse"
B. "I will take aspirin for eye discomfort"
C. "I can blow my nose to clear out any drainage"
D. "I can lift objects up to 20 lbs"
Answer: A. "I should call my doctor if my vision gets worse. "
Rationale:
The client should expect an improvement in vision after the surgery, so the nurse should instruct
the client to report negative changes in vision immediately.
"I will take aspirin for eye discomfort. "The client should avoid aspirin because it can cause
bleeding in the eye.
"I can blow my nose to clear out any drainage. "The client should avoid blowing their nose
because it can increase intraocular pressure. "I can lift objects up to 20 pounds. "The client
should avoid lifting objects heavier than 4. 5 kg (10 lb) because it can increase intraocular
pressure.
A nurse is assessing a client who has a head injury following a motorvehicle crash. The nurse
should identify that which of the following findings indicates increasing intracranial pressure?
A. Restlessness
B. Dizziness
C. HPTN
D. Fever
Answer: A. RestlessnessRationale:
Behavioral changes, such as restlessness and irritability, are early manifestations of increased
intracranial pressure.
Dizziness Although dizziness might be present after head trauma, it is not a manifestation of
increased intracranial pressure.
Hypotension Although hypotension might be present after head trauma, especially if the client is
experiencing hypovolemic or neurogenic shock, it is not a manifestation of increased intracranial
pressure. Cushing's triad of hypertension, bradycardia, and a widening pulse pressure is a late
manifestation of increased intracranial pressure.
Fever Although a client who has head trauma can develop fever, it is either in response to
infection or due to hypothalamic damage, not due to increased intracranial pressure.
A nurse is assessing a client who had a right hemisphere stroke. Which of the following
neurologic deficits should the nurse expect?
A. Aphasia
B. Right-sided neglect
C. Impulsive behavior
D. Inability to read
Answer: C. 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.
Aphasia Clients who had a left hemispheric stroke are likely to have aphasia.
Right-sided neglect Clients who had a right hemispheric stroke are likely to have neurologic
deficits on the left side of the body, not the right side. The nurse should expect the client to be
unaware of and unable to move the left side of the body. Inability to read clients who had a left
hemispheric stroke are likely to have difficulty reading due to the inability to discriminate
different letters and words.
A nurse is planning to teach a client who has epilepsy and a new prescription for phenytoin.
Which of the following instructions should the nurse plan to include?
A. Rinse with antiseptic mouthwash instead of using dental floss
B. Use an OTC antihistamine if a rash develops
C. Slowly taper the medication after 6 consecutive months without seizure activity
D. Take medications at a consistent time each day to maintain therapeutic blood levels
Answer: D. Take medications at a consistent time each day to maintain therapeutic blood levels.
Rationale:
The nurse should teach the client to take antiepileptic medications on a regular schedule to
maintain therapeutic blood levels and achieve the maximum effect.
Rinse with antiseptic mouthwash instead of using dental floss. The nurse should teach the client
that phenytoin can cause gingival hyperplasia, an overgrowth of gum tissue. To minimize gum
injury and discomfort, the client should brush and floss after each meal, massage their gums, and
schedule dental examinations regularly.
Use an over-the-counter antihistamine if a rash develops. The nurse should teach the client to
stop taking phenytoin if a rash develops and to report the development of a rash to the provider
immediately. An adverse effect of phenytoin therapy is the development of a measles like rash. If
left untreated, the rash could progress to Stevens-Johnson syndrome or toxic epidermal
necrolysis.
Slowly taper the medication after 6 consecutive months without seizure activity. The nurse
should teach the client to continue taking antiepileptic medications even in the absence of
seizures. Stopping the medication can lead to the return of seizures or the complication of status
epilepticus.
A nurse is teaching a client who has Parkinson's disease and is prescribed carbidopa-levodopa.
Which of the following client statements indicates an understanding of the teaching?
A. "I should expect an increase in my blood pressure while taking this medication"
B. "I should take this medication 2 hr after meals to increase absorptions"
C. "I should expect that this medication can cause me to be drowsy" D. "I should expect this
medication to be effective within 48 hrs"
Answer: C. "I should expect that this medication can cause me to be drowsy. "
Rationale:
Drowsiness is a known adverse effect of carbidopa-levodopa; therefore, clients are taught to
avoid heavy machinery and driving if they experience drowsiness.
"I should expect an increase in my blood pressure while taking this medication. "Orthostatic
hypotension is an adverse effect of carbidopa-levodopa.
"I should take this medication 2 hours after meals to increase absorption. "-Carbidopa-levodopa
should be administered before meals to increase absorption and transport the medication across
the blood brain barrier.
"I should expect this medication to be effective within 48 hours. " The nurse should inform the
client that the medication can take 2 to 3 months to take effect.
A nurse is teaching a client who has multiple sclerosis and has a new prescription for glatiramer
acetate. Which of the following statements indicates that the client understands the teaching?
A. "I will ask my partner to give the injection in the same spot each time"
B. "I will avoid going to the store when it is crowded"
C. "I will see relief of my symptoms in about 1 wk"
D. " I will exercise rigorously while taking this medication"
Answer: B. "I will avoid going to the store when it is crowded. "- Clients who are prescribed
this medication are instructed to avoid crowds and individuals who have infection.
Rationale:
"I will ask my partner to give the injection in the same spot each time. " Clients are instructed to
rotate the site of injection because local skin reactions are common.
"I will see relief of my symptoms in about 1 week. "Clients are instructed that it may take up to 6
months for the immune response to become evident.
"I will exercise rigorously while taking this medication. "Clients who have multiple sclerosis are
instructed to avoid activities that increase their temperature, which leads to fatigue.
A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which of the
following interventions is the nurse's priority?
A. Provide frequent rest period throughout the day
B. Administer pain medication on a regular schedule
C. Monitor pulse oximetry findings
D. Administer baclofen for spasticity
Answer: C. Monitor pulse oximetry findings.
Rationale:
The greatest risk to the client is respiratory compromise due to progressive paralysis of
respiratory muscles. Therefore, the priority intervention is to monitor the client's oxygen
saturation to identify respiratory compromise as soon as possible.
Provide frequent rest periods throughout the day. The nurse should provide frequent rest periods
throughout the day because the client's fatigue will increase as the disease progresses. However,
this is not the priority intervention.
Administer pain medication on a regular schedule. The nurse should administer pain medication
on a regular schedule to keep the client's pain level under control. However, this is not the
priority intervention. Administer baclofen for spasticity.
The nurse should administer baclofen to manage spasticity that can interfere with self-care.
However, this is not the priority intervention
A nurse in an emergency department is assessing a client who reports sudden, severe eye pain
with blurry vision. The provider determines that the client has primary angle-closure glaucoma.
Which of the following medications should the nurse expect to administer?
A. Osmotic diuretics via IV bolus
B. Mydriatic ophthalmic drops
C. Corticosteroid ophthalmic drops
D. Epinephrine via IV bolus
Answer: A. Osmotic diuretics via IV bolus
Rationale:
The nurse should expect to administer prescribed osmotic diuretics, such as mannitol, to reduce
intraocular pressure and prevent damage to the eye.
Mydriatic ophthalmic drops. Clients who have primary angle-closure glaucoma should not
receive mydriatic ophthalmic drops because they cause pupillary dilation. Instead, the nurse
should expect to administer medications that decrease intraocular pressure by increasing the
absorption or decreasing the production of aqueous humor. Corticosteroid ophthalmic dropsCorticosteroid ophthalmic drops are used for inflammatory conditions of the eye, such as
conjunctivitis. There is no indication for clients who have primary angle-closure glaucoma to
receive corticosteroid ophthalmic drops. Instead, the nurse should expect to administer
medications that decrease intraocular pressure by increasing the absorption or decreasing the
production of aqueous humor.
Epinephrine via IV bolus Clients who have primary angle-closure glaucoma should not receive
epinephrine-containing medications because they cause vasoconstriction. Instead, the nurse
should expect to administer medications that decrease intraocular pressure by increasing the
absorption or decreasing the production of aqueous humor.
A nurse is teaching an assistive personnel (AP) about providing care to a client following a total
hip arthroplasty. Which of the following instructions should the nurse include?
A. Avoid applying antiembolism stockings to the affected leg
B. Have the client lean forward when moving from a sitting to a standing position
C. Discourage the client from sitting in a wheelchair with the back reclined
D. Place an abductor pillow between the client's legs when turning the client
Answer: D. Place an abductor pillow between the client's legs when turning the client. Rationale:
The nurse should inform the AP that a client who had a total hip arthroplasty should maintain the
hip in abduction following surgery to reduce the risk of dislocating the affected hip. The AP
should place an abductor pillow between the client's legs when turning the client to keep the hips
in abduction.
Avoid applying antiembolism stockings to the affected leg. -The nurse should instruct the AP that
a client who had a total hip arthroplasty should wear antiembolism stockings on both legs
postoperatively to prevent the development of emboli in the lower extremities. Have the client
lean forward when moving from a sitting to a standing position. -The nurse should instruct the
AP that a client who had a total hip arthroplasty should use the unaffected leg and arms to push
straight up to standing and not flex the affected hip more than 90°. Discourage the client from
sitting in a wheelchair with the back reclined. - The nurse should instruct the AP that a client
who had a total hip arthroplasty can sit in either an upright wheelchair or one with a back that
reclines to prevent hip flexion greater than 90
A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder.
Which of the following assessment findings should the nurse report to the provider?
A. Glasgow Coma Scale score of 15
B. Intracranial pressure reading of 15 mm Hg
C. Ecchymosis at base of skull
D. Clear drainage from nose
Answer: D. Clear drainage from noseRationale:
Clear drainage from the nose indicates that cerebrospinal fluid is leaking from the skull fracture.
This places the client at risk for meningeal infection because micro-organisms have access to the
cranium through the nose and the tear in the dura. The nurse should report this finding to the
provider.
Glasgow Coma Scale score of 15. A Glasgow Coma Scale score of 15 indicates intact neurologic
functioning and does not need to be reported to the provider. Intracranial pressure reading of 15
mm Hg-An intracranial pressure reading of 15 mm Hg is at the upper limit of the expected
reference range and does not need to be reported to the provider.
Ecchymosis at base of skull- A client who has a basilar skull fracture is likely to have
ecchymosis at the base of the skull from a contusion and this finding does not need to be
reported to the provider.
A nurse is caring for a client who has multiple sclerosis. Which of the following should the nurse
expect?
A. Hypoactive deep-tendon reflexes
B. Ascending paralysis
C. Intention tremors
D. Increased lacrimation
Answer: C. Intention tremors
Rationale:
Clients who have multiple sclerosis are at risk for motor dysfunction, with intention tremors,
poor coordination, and loss of balance.
Hypoactive deep-tendon reflexes-Clients who have multiple sclerosis have hyperactive deeptendon reflexes.
Ascending paralysis-Clients who have Guillain-Barré syndrome are at risk for ascending
paralysis.
Increased lacrimation-Increased lacrimation, or tearing of the eyes, is an expected finding of
myasthenia gravis during a cholinergic crisis.
A nurse is caring for a client who is recovering from a stroke an has right-sided homonymous
hemianopsia. To help the client adapt to the hemianopsia, the nurse should take which of the
following actions?
A. Check the client's cheek on the affected side after meals to be sure no food remains there
B. Encourage the client to sit upright with their head tilted slightly forward during meals
C. Provide the client with eating utensils that have large handles
D. Remind the client to look consciously at both sides of their meal tray
Answer: D. Remind the client to look consciously at both sides of their meal tray.
Rationale:
Clients who have right-sided homonymous hemianopsia have lost the right visual field of both
eyes and might only eat the food they are able to see on the left half of the meal tray. Therefore,
the nurse should remind the client to look at both sides of his meal tray to help compensate for
the visual loss
Check the client's cheek on the affected side after meals to be sure no food remains there.
Homonymous hemianopsia does not cause the client to pocket food. However, food can
accumulate on the affected side of the mouth, so the nurse should place food on the unaffected
side of the client's mouth when assisting with eating.
Encourage the client to sit upright with their head tilted slightly forward during meals. Homonymous hemianopsia does not cause dysphagia. However, as stroke can cause dysphagia,
positioning the client upright and having them tilt their head forward to swallow can help
prevent aspiration.
Provide the client with eating utensils that have large handles. Homonymous hemianopsia does
not impair the client's fine motor skills. However, as stroke can impair fine motor skills, eating
utensils that have a wide grip surface can help compensate for a weak hand grasp.
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?
A. Client's vital sign changes
B. Client's report of the type of pain
C. Client's nonverbal communication
D. Client's report of pain on a pain scale
Answer: D. Client's report of pain on a pain scale
Rationale:
The nurse should use a client's report of pain on a standardized pain scale to determine the
severity of the client's pain.
Client's vital sign changes- A change in vital signs can identify that pain is present, but the nurse
should use another finding to determine the severity of the client's pain.
Client's report of the type of pain- report of the type of pain identifies the character of the pain,
such as sharp or dull, but the nurse should use another finding to determine the severity of the
client's pain. Client's nonverbal communication-Facial grimacing can identify that pain is
present, but the nurse should use another finding to determine the severity of the client's pain.
A nurse in an emergency department is caring for a client who suddenly lost consciousness and
fell wile at home. The provider determines that the client had an embolic stroke. Which of the
following medications should the nurse expect to administer?
A. Tissue plasminogen activator
B. Recombinant factor VIII
C. Nitroglycerin
D. Lidocaine
Answer: A. Tissue plasminogen activator
Rationale:
Tissue plasminogen activator is a thrombolytic agent that should dissolve the blood clot that
caused the stroke.
Recombinant factor VIII- Recombinant factor VIII helps manage the manifestations of
hemophilia.
Nitroglycerin-Nitroglycerin is a coronary and venous vasodilator that treats angina.
Lidocaine- Lidocaine is an antidysrhythmic agent that treats ventricular dysrhythmias
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?
A. Reposition the client
B. Check the position of the weights and ropes
C. Administer a muscle relaxant
D. Provide distraction
Answer: B. Check 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
Reposition the client. - The nurse should reposition the client to realign him and try to relieve his
muscle spasms. However, there is another action the nurse should take first.
Administer a muscle relaxant. - The nurse should administer a muscle relaxant to minimize the
client's muscle spasms. However, there is another action the nurse should take first.
Provide distraction. - The nurse should provide sensory stimulation to help the client keep his
focus away from the pain of the spasms. However, there is another action the nurse should take
first.
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 facial flushing and a
blood pressure of 220/110mm Hg. Which of the following actions should the nurse take first?
A. Administer hydralazine via IV bolus
B. Loosen the client's clothing
C. Empty the client's bladder
D. Elevate the head of the client's bed
Answer: D. Elevate the head of the client's bed. - These assessment findings indicate that the
client is experiencing autonomic dysreflexia and is at greatest risk for possible rupture of a
cerebral vessel or increased intracranial pressure. The first action the nurse should take is to
move the client from a supine to an upright position, which will result in rapid postural
hypotension.
Rationale:
Administer hydralazine via IV bolus. - The nurse should administer hydralazine, a potent
vasodilator, to lower the client's blood pressure. However, there is another action the nurse
should take first.
Loosen the client's clothing. -The nurse should loosen the client's clothing because body
temperature and tactile stimulation are triggers of autonomic dysreflexia. However, there is
another action the nurse should take first.
Empty the client's bladder. - The nurse should empty the client's bladder because a full bladder or
a fecal impaction is a trigger of autonomic dysreflexia. However, there is another action the
nurse should take first.
