NUR202: Ch. 39, 40, & 41

A client with early-stage Alzheimer disease is admitted to the hospital with chest pain. Which nursing action is most appropriate to manage this client’s dementia?

• • Provide animal-assisted therapy as needed.

• • Ensure a structured and consistent environment.

• • Assist the client with activities of daily living (ADLs).

• • Use validation therapy when communicating with the client.

The nurse prepares to discharge a client with early to moderate Alzheimer disease. Which statement to maintain client safety would the nurse include in the discharge teaching for the caregiver?

• • “Provide periods of exercise and rest for the client.”

• • “Place a padded throw rug at the bedside.”

• • “Provide a highly stimulating environment.”

• • “Install safety locks on all outside doors.”

The nurse plans care for a client with Parkinson disease. Which intervention would the nurse include in this client’s plan of care?

• • Restrain the client to prevent falling.

• • Ensure that the client uses incentive spirometry.

• • Teach the client pursed-lip breathing techniques.

• • Keep the head of the bed at 30 degrees or greater.

The nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. What action would the nurse take first?

• • Start fluids via a large-bore catheter.

• • Administer IV push diazepam.

• • Turn the client’s head to the side.

• • Prepare to intubate the client.

The nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions would the nurse include in this client’s plan of care? (Select all that apply.)

• • Have suction equipment with an airway at the bedside.

• • Place a padded tongue blade at the bedside.

• • Permit only clear oral fluids.

• • Have oxygen administration set at the bedside.

• • Ensure that the client has IV access.

A client who has multiple sclerosis reports increased severe muscle spasticity and tremors. What nursing action is most appropriate to manage this client’s concern?

• • Request a prescription for an antispasmodic drug such as baclofen.

• • Prepare the client for deep brain stimulation surgery.

• • Refer the client to a massage therapist to relax the muscles.

• • Consult with the occupational therapist for self-care assistance.

A nurse assesses a client with a spinal cord injury at level T5. The client’s blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. After raising the head of the bed, what action would the nurse take next?

• • Initiate oxygen via a nasal cannula.

• • Recheck the client’s blood pressure.

• • Palpate the bladder for distention.

• • Administer a prescribed beta blocker.

After teaching a client with a high thoracic spinal cord injury, the nurse assesses the client’s understanding. Which statement by the client indicates a correct understanding of how to prevent respiratory problems at home?

• • “I’ll use my incentive spirometer every 2 hours while I’m awake.”

• • “I’ll drink thinned fluids to prevent choking.”

• • “I’ll take cough medicine to prevent excessive coughing.”

• • “I’ll position myself on my right side so I don’t aspirate.”

A nurse assesses a client who is recovering from an open anterior cervical discectomy and fusion. Which complication would alert the nurse to urgently communicate with the primary health care provider?

• • Auscultated stridor

• • Weak pedal pulses

• • Difficulty swallowing

• • Inability to shrug shoulders

A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client’s hips and sacrum. What actions would the nurse take? (Select all that apply.)

• • Apply a barrier cream to protect the skin from excoriation.

• • Perform range-of-motion (ROM) exercises for the hip joint.

• • Reposition the client off of the reddened areas.

• • Get the client out of bed and into a chair several times a day.

• • Apply a pressure-reducing mattress.