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Question 1
Free
Multiple Choice

The nurse is assessing a client with newly diagnosed trigeminal neuralgia. Which of the following parameters should the nurse assess?

Choose correct answer/s
A

Triggers that lead to facial pain

B

Visual problems caused by ptosis

C

Poor appetite caused by a loss of taste

D

Weakness on the affected side of the face

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Question 2
Free
Multiple Choice

Which of the following actions should the nurse take when assessing a client with trigeminal neuralgia?

Choose correct answer/s
A

Examine the mouth and teeth thoroughly.

B

Have the client clench and relax the jaw and eyes.

C

Identify trigger zones by lightly touching the affected side.

D

Gently palpate the face to compare skin temperature bilaterally.

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Question 3
Free
Multiple Choice

The nurse is caring for a client with trigeminal neuralgia who has had a glycerol rhizotomy. Which of the following interventions should the nurse implement?

Choose correct answer/s
A

Ask whether the client is using an eye shield at night.

B

Determine whether the client is doing daily facial exercises.

C

Question the client about social activities with family and friends.

D

Remind the client to chew food on the unaffected side of the mouth.

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Question 4
Free
Multiple Choice

Which of the following actions should the nurse include in the plan of care when caring for a client who is experiencing trigeminal neuralgia?

Choose correct answer/s
A

Teach facial and jaw relaxation techniques.

B

Assess intake and output and dietary intake.

C

Apply ice packs for no more than 20 minutes.

D

Spend time at the bedside talking with the client.

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Question 5
Free
Multiple Choice

The nurse is teaching a client who is at risk for Bell's palsy because of previous herpes simplex infection. Which of the following information should the nurse include?

Choose correct answer/s
A

"Call the doctor if pain or herpes lesions occur near the ear."

B

"Treatment of herpes with antiviral agents prevents Bell's palsy."

C

"You may be able to prevent Bell's palsy by doing facial exercises regularly."

D

"Medications to treat Bell's palsy work only if started before paralysis onset."

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Question 6
Multiple Choice

The nurse is caring for a client with Bell's palsy who refuses to eat while others are present because of embarrassment about drooling. Which of the following responses is best for the nurse to do?

Choose correct answer/s
A
Respect the client's desire and arrange for privacy at mealtimes.
B
Teach the client to chew food on the unaffected side of the mouth.
C
Offer the client liquid nutritional supplements at frequent intervals.
D
Discuss the client's concerns with visitors who arrive at mealtimes.
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Question 7
Multiple Choice

Which of the following nursing actions should the home health nurse include in the plan of care for a client with paraplegia in order to prevent autonomic dysreflexia?

Choose correct answer/s
A
Assist with selection of a high protein diet.
B
Use quad coughing to assist cough effort.
C
Discuss options for sexuality and fertility.
D
Teach the purpose of a prescribed bowel program.
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Question 8
Multiple Choice

The nurse is caring for a client who has Guillain-Barré syndrome. Which of the following assessment data obtained by the nurse will require the most immediate action?

Choose correct answer/s
A
The client has continuous drooling of saliva.
B
The client's blood pressure (BP) is 106/50 mm Hg.
C
The client's quadriceps and triceps reflexes are absent.
D
The client complains of severe tingling pain in the feet.
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Question 9
Multiple Choice

The nurse is caring for a client who has numbness and weakness of both feet and who is hospitalized with Guillain-Barré syndrome. Which of the following information should the nurse include in the client's plan of care?

Choose correct answer/s
A
Intubation and mechanical ventilation
B
Administration of IV corticosteroid drugs
C
Insertion of a nasogastric (NG) feeding tube
D
IV infusion of high dose immunoglobulin (IVIG)
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Question 10
Multiple Choice

A client arrives at an urgent care centre with a deep puncture wound after stepping on a nail that was lying on the ground. The client reports having had a tetanus booster 7 years ago. Which of the following actions should the nurse anticipate?

Choose correct answer/s
A
IV infusion of tetanus immune globulin (TIG)
B
Administration of the tetanus-diphtheria (Td) booster
C
Intradermal injection of an immune globulin test dose
D
Initiation of the tetanus-diphtheria immunization series
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Question 11
Multiple Choice

The nurse is caring for a client with a neck fracture at the C5 level in the intensive care unit. During initial assessment of the client, the nurse recognizes the presence of neurogenic shock upon assessing which of the following findings?

Choose correct answer/s
A
Hypotension, bradycardia, and warm extremities
B
Involuntary, spastic movements of the arms and legs
C
Hyperactive reflex activity below the level of the injury
D
Lack of movement or sensation below the level of the injury
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Question 12
Multiple Choice

The nurse is caring for a client who has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which of the following nursing actions should be included in the plan of care?

Choose correct answer/s
A
Assessment of the client for left leg pain
B
Assessment of the client for left arm weakness
C
Positioning the client's right leg when turning the client
D
Teaching the client to look at the left leg to verify its position
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Question 13
Multiple Choice

The nurse is caring for a client with a T1 spinal cord injury in the intensive care unit. Which of the following information should the nurse include in the teaching plan for the client and family?

Choose correct answer/s
A
Use of the shoulders will be preserved.
B
Full function of the client's arms will be retained.
C
Total loss of respiratory function may occur temporarily.
D
Elevations in heart rate are common with this type of injury.
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Question 14
Multiple Choice

The nurse is caring for a client with paraplegia resulting from a T10 spinal cord injury who has a neurogenic reflex bladder. Which of the following actions should the nurse include in the plan of care?

Choose correct answer/s
A
Educate on the use of the Credé method.
B
Teach the client how to self-catheterize.
C
Catheterize for residual urine after voiding.
D
Assist the client to the toilet every 2 hours.
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Question 15
Multiple Choice

The nurse is developing a rehabilitation plan for a client with a C6 spinal cord injury. Which of the following goals should the nurse include for this client?

Choose correct answer/s
A
Transfer independently to a wheelchair.
B
Drive a car with powered hand controls.
C
Turn and reposition independently when in bed.
D
Push a manual wheelchair on flat, smooth surfaces.
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Question 16
Multiple Choice

The nurse is caring for a client who sustained a spinal cord injury a week ago and becomes angry, telling the nurse "I want to be transferred to a hospital where the nurses know what they are doing!" Which of the following actions by the nurse is best?

Choose correct answer/s
A
Ask for the client's input into the plan for care.
B
Clarify that abusive behaviour will not be tolerated.
C
Reassure the client about the competence of the nursing staff.
D
Continue to perform care without responding to the client's comments.
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Question 17
Multiple Choice

After a young adult client has returned home following rehabilitation for a spinal cord injury, the home care nurse notes that the partner is performing many of the activities that the client had been managing during rehabilitation. Which of the followingactions by the nurse is most appropriate at this time?

Choose correct answer/s
A
Tell the partner that the client can perform activities independently.
B
Remind the client about the importance of independence in daily activities.
C
Develop a plan to increase the client's independence in consultation with the client and the partner.
D
Recognize that it is important for the partner to be involved in the client's care and support the partner's participation.
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Question 18
Multiple Choice

The health care provider prescribes these interventions for a client with possible botulism poisoning. Which of the following prescriptions should the nurse question?

Choose correct answer/s
A
Maintain NPO status.
B
Obtain lumbar puncture tray.
C
Give magnesium citrate 240 mL stat.
D
Administer 1 500 mL tap water enema.
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Question 19
Multiple Choice

The nurse is caring for a client who was admitted 24 hours previously with a C5 spinal cord injury. Which of the following nursing actions has the highest priority?

Choose correct answer/s
A
Assessment of respiratory rate and depth
B
Continuous cardiac monitoring for bradycardia
C
Application of pneumatic compression devices to both legs
D
Administration of methylprednisolone infusion
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Question 20
Multiple Choice

The nurse is caring for a client who has onset Guillain-Barré syndrome. During this phase of the client's illness, which of the following parameters is the most important for the nurse to assess?

Choose correct answer/s
A
Monitor the cardiac rhythm.
B
Determine level of consciousness.
C
Check strength of the extremities.
D
Observe respiratory rate and effort.
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