ATI Targeted Medical Surgical Neurosensory and Musculoskeletal Exam (Answered with Rationales) A nurse is assessing a client who had a right hemisphere
... [Show More] stroke. Which of the following neurologic deficits should the nurse expect? A. Aphasia B. Right-sided neglect C. Impulsive behavior D. Inability to read 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 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" 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" Clients who are prescribed this medication are instructed to avoid crowds and individuals who have infection. "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 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 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 drops-Corticosteroid 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 [Show Less]